The nature of progression on active surveillance for grade group 2 prostate cancer.

Abstract

330 Background: Active surveillance (AS) is included in guidelines as a management option for men with Gleason Grade Group 2 (GG2; Gleason 3+4) prostate cancer (PCa), but uptake has been limited and variable between providers. We sought to describe progression of confirmed GG2 disease in a well-annotated AS cohort. Methods: The Urologic Outcomes Database (UODB) at the University of California San Francisco (UCSF) was queried for men with cT1-2N0/xM0/x, PSA <20 ng/mL, core positivity ≤50%, GG2 PCa, and ≥2 biopsies on AS. Outcomes were upgrade (≥GG3), increase in positive cores to >50%, disease progression (either upgrade or increase in core positivity to >50%), active treatment, metastasis, and prostate cancer–specific mortality (PCSM). Life-table estimates described outcomes, and Cox regression identified factors associated with risk of progression. Results: 319 men met inclusion criteria. Median (IQR) follow-up was 70 (42–104) months. CAPRA score was low risk in 159 (50%) and intermediate risk in 160 (50%). Median (IQR) PSA was 5.4 (4.1–7.4) ng/mL. 184 (57%) men had genomic testing (Decipher or GPS), and 221 (69%) had multiparametric prostate MRI (mpMRI). At 5 and 10 years, upgrade rate was 34% and 67%, increase in core positivity >50% was 16% and 19%, disease progression 44% and 76%, active treatment 45% and 65%, and metastasis 0.9% and 3.4%, respectively. No PCSM events were recorded. Initial core positivity and PSA density were associated with volume increase >50%, and PSA density (≥0.15) and positive mpMRI (PIRADS 4–5 vs 1–3) were significantly associated with disease progression and active treatment (Table 1). Genomic testing was not significantly associated with outcomes. Conclusions: Men with confirmed GG2 PCa on AS have moderate rates of progression requiring treatment at 10 years, but low metastasis and mortality rates suggest safety in well-selected patients. Positive mpMRI and increased PSA density may help tailor AS intensity. Multivariable Cox proportional hazards regression models for risk factors for progression and active treatment in 319 patients with GG2 prostate cancer. Disease progression (≥GG3 or increased core positivity >50%) Progression to Active treatment Parameter HR (95% CI) p-value HR (95% CI) p-value Year of diagnosis (per year) 1.03 (0.98-1.19) 0.24 1.03 (0.98-1.08) 0.26 Age at diagnosis (per 10 years) 1.09 (0.86-1.39) 0.47 0.96 (0.80-1.16) 0.70 Percent Positive Biopsy Cores (log-adjusted) 1.22 (0.90-1.67) 0.20 1.22 (0.94-1.58) 0.14 PSA density (≥0.15 vs <0.15) 2.08 (1.41-3.06) 0.03 1.47 (1.07-2.01) 0.02 Positive MRI (PIRADS 4-5 vs 1-3) 2.17 (1.16-4.06) 0.02 2.03 (1.22-3.38) 0.01 Genomic testing (GPS or Decipher, High vs Low) 0.70 (0.35-1.39) 0.32 0.98 (0.58-1.64) 0.93