Contemporary risk of biochemical recurrence after radical prostatectomy in the active surveillance era

Sanjay Das; Michael Luu; Martha Terris; Zachary Klaassen; Christopher J Kane; Christopher Amling; Matthew Cooperberg; Lourdes Guerrios Rivera; William Aronson; Stephen J Freedland; Timothy J Daskivich

doi:10.1016/j.urolonc.2024.02.010

Contemporary risk of biochemical recurrence after radical prostatectomy in the active surveillance era

Urol Oncol. 2024 Jun;42(6):175.e1-175.e8. doi: 10.1016/j.urolonc.2024.02.010. Epub 2024 Mar 15.

Authors

Affiliations

¹ Durham Veterans Affairs Health Care System, Department of Surgery, Durham, NC; Department of Urology, University of California - Los Angeles, Los Angeles, CA; Department of Urology, Cedars-Sinai Medical Center, Los Angeles.
² Department of Biostatistics and Bioinformatics, Cedars-Sinai Medical Center, Los Angeles, CA.
³ Division of Urology, Charlie Norwood VA Medical Center, Augusta, GA; Department of Urology, Augusta University-Medical College of Georgia, Augusta, GA.
⁴ Department of Urology, University of California, San Diego, CA.
⁵ Department of Urology, Oregon Health Sciences University, Portland, OR.
⁶ Department of Urology, University of California, San Francisco, CA; Section of Urology, San Francisco VA Medical Center, San Francisco, CA.
⁷ VA Caribbean Healthcare System, San Juan, PR; Department of Surgery, University of Puerto Rico, San Juan, PR.
⁸ Department of Urology, University of California - Los Angeles, Los Angeles, CA; Greater Los Angeles Veterans Affairs, Los Angeles, CA.
⁹ Durham Veterans Affairs Health Care System, Department of Surgery, Durham, NC; Department of Urology, Cedars-Sinai Medical Center, Los Angeles; Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
¹⁰ Department of Urology, Cedars-Sinai Medical Center, Los Angeles; Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address: Timothy.Daskivich@cshs.org.

PMID: 38490923
DOI: 10.1016/j.urolonc.2024.02.010

Abstract

Objectives: To assess whether contemporary risks of biochemical recurrence (BCR) after radical prostatectomy (RP) in the AS era differ from historical estimates due to changes in tumor risk case mix and improvements in risk stratification.

Materials and methods: We sampled 6,682 men who underwent RP for clinically localized disease between 2000 and 2017 from the VA SEARCH database. Kaplan Meier analysis was used to calculate incidence of BCR before and after 2010 overall and within tumor risk subgroups. Multivariable Cox proportional hazard regression analysis including an interaction term between era and tumor risk was used to compare risk of BCR before and after 2010 overall and across tumor risk subgroups.

Results: About 3,492 (52%) and 3,190 (48%) men underwent RP before and after 2010, respectively. In a limited multivariable model excluding tumor risk, overall BCR risk was higher post-2010 vs. pre-2010 (HR: 1.15, 95%CI: 1.05-1.25; 40% vs 36% at 8 years post-RP). However, this effect was eliminated after correcting for tumor risk (HR: 0.95, 95%CI: 0.87-1.04), suggesting that differences in tumor risk between eras mediated the change. Yet, within tumor-risk subgroups, BCR risk was significantly lower for favorable intermediate-risk (HR: 0.76, 95%CI:0.60-0.96) and unfavorable intermediate-risk PC (HR: 0.78, 95%CI: 0.67-0.90), but significantly higher for high-risk PC (HR: 1.22, 95%CI: 1.07-1.38) in the post-2010 era. 8-year risks of BCR in the post-2010 era were 21% (95%CI: 16%-25%), 25% (95%CI: 20%-30%), 41% (95%CI: 37%-46%), and 60% (95%CI: 56%-64%) for low-, FIR-, UIR-, and high-risk disease, respectively. Limitations include limited long-term follow-up in the post-2010 subgroup.

Conclusions: Overall BCR risk has increased in the AS era, driven by a higher risk case mix and increased BCR risk among high-risk patients. Physicians should quote contemporary estimates of BCR when counseling patients.

Keywords: “Active surveillance”; “Biochemical recurrence”; “Prostate cancer”; “Radical prostatectomy”.

MeSH terms

Aged
Humans
Male
Middle Aged
Neoplasm Recurrence, Local* / epidemiology
Prostate-Specific Antigen / blood
Prostatectomy* / methods
Prostatic Neoplasms* / blood
Prostatic Neoplasms* / surgery
Risk Assessment / methods
Risk Factors
Watchful Waiting

Substances

Prostate-Specific Antigen