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New England Section of the American Urological Association

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Evaluating the AUA Guidelines: cT2b-c Grade Group 1 Prostate Cancer
Esther L. Finney, MD, Kristian D. Stensland, MD, MPH, David Canes, MD, Andrea Sorcini, MD, Alireza Moinzadeh, MD, Harras B. Zaid, MD.
Lahey Hospital and Medical Center, Burlington, MA, USA.

Background: The AUA and NCCN guidelines broadly stratify prostate cancers into low, intermediate (including favorable and unfavorable), and high risk groups to guide management. Included within the unfavorable intermediate risk category are patients with clinical T2b-c, grade group 1 (GG1) cancer with elevated PSA between 10-20. The AUA guidelines state that these patients “may not represent unfavorable risk disease”, though little data exists to guide management here. Therefore, we aimed to assess whether the disease severity and outcomes of this subgroup more closely align with favorable or unfavorable intermediate risk prostate cancer.
Materials & Methods: The National Cancer Database was queried for all non-metastatic prostate cancer cases from 2010-2015. Patients were stratified into low, favorable intermediate, unfavorable intermediate, and high-risk groups by clinical T stage, GG, and PSA, according to the current AUA guidelines. Patients with GG1 clinical T2b-c disease were further separated into two distinct groups based on PSA (<10 vs 10-20) . We compared 5-year overall survival (OS) using the Kaplan-Meier method and log-rank test for all patients, and stratified by treatment received (surgery or radiation). We then assessed associations with OS using a multivariable Cox proportional hazards model.
Results: A total of 482,378 cases were included, of which 31% were low, 25% favorable intermediate, 18% unfavorable intermediate, and 24% high risk. Men with cT2b-c, GG1, PSA <10 comprised 1.67% (8065); cT2b-c, GG2, PSA 10-20 comprised 0.2% (1005). Patients with GG1, cT2b-c, PSA 10-20 disease had similar OSl at 5 years to the unfavorable intermediate-risk group regardless of treatment modality (surgery: 93.4% vs 92.8%; radiation: 79.4% vs 81.9%, both p>0.05). In the multivariable model, the cT2b-c, GG1, PSA 10-20 risk factor had a similar effect on survival as the unfavorable intermediate group factor (HR 1.12, 95% CI 0.91-1.37, p = 0.29). In contrast, patients with cT2b-c, GG1, PSA <10 had 5 year OS rates of 93%, comparable to men in the low-risk category (92.6%, p=0.14) and significantly better than that of men in the intermediate favorable risk category (90%, p<0.001). Survival was similar when stratified by treatment and on multivariable modeling.
Conclusions: Men with cT2b-c, GG1, PSA 10-20 disease have OS rates similar to those of men with unfavorable intermediate-risk disease regardless of treatment modality chosen. For men with PSA<10 in this same strata, outcomes were similar to low risk disease and significantly better than the intermediate favorable risk group.

Figure 2: Cox proportional-hazards model for 5 year overall survival
VariableHR (95% CI)p value
Insurance Status
Uninsured (base)(reference)
Private insurance/Managed care0.72 (0.66-0.78)<0.001
Medicaid1.13 (1.03-1.25)0.012
Medicare0.90(0.83-0.98)0.016
Percent No High School Degree Quartiles (2012-2016)
>17.5% (base)(reference)
10.9-17.5%1.04 (1.00-1.07)0.026
6.3-10.8%0.99 (0.95-1.02)0.460
<6.3%0.91 (0.87-0.95)<0.001
Year of Diagnosis
2010 (base)(reference)
20111.07 (1.04-1.11)<0.001
20121.07 (1.03-1.10)<0.001
20131.13 (1.08-1.17)<0.001
20141.19 (1.14-1.24)<0.001
20151.17 (1.11-1.23)<0.001
Age1.05 (1.05-1.07)<0.001
Median Income Quartiles (2012-2016)
<$40,227 (base)(reference)
$40,227-50,3530.86 (0.84-0.89)<0.001
$50,354-63,3320.82 (0.79-0.85)<0.001
>=$63,3330.71 (0.68-0.74)<0.001
Charlson-Deyo Score
0 (base)(reference)
11.45 (1.41-1.49)<0.001
22.15 (2.05-2.25)<0.001
32.86 (2.66-3.07)<0.001
Facility Type
Community Cancer Program (base)(reference)
Comprehensive Community Cancer Program0.95 (0.91-0.98)0.003
Academic/Research Program0.79 (0.76-0.82)<0.001
Integrated Network Cancer Program0.93 (0.89-0.97)<0.001
Risk Category
Low (base)(reference)
cT2b-c, GG1, PSA <101.10 (1.10-1.22)0.070
Favorable intermediate1.36 (1.32-1.41)<0.001
Unfavorable intermediate1.60 (1.58-1.70)<0.001
cT2b-c, GG1, PSA 10-201.83 (1.49-2.25)<0.001
High2.52 (2.45-2.60)<0.001
Risk Category
Low0.61 (0.59-0.63)<0.001
cT2b-c, GG1, PSA <100.67 (0.61-0.75)<0.001
Favorable intermediate0.83 (0.80-0.86)<0.001
Unfavorable intermediate (base)(reference)
cT2b-c, GG1, PSA 10-201.10 (0.91-1.37)0.285
High1.54 (1.49-1.59)<0.001
Treatment Type
No treatment (base)(reference)
Surgery alone0.31 (0.30-0.32)<0.001
Radiation alone0.56 (0.55-0.58)<0.001
Surgery and radiation0.45 (0.42-0.48)<0.001
HR = hazard ratio; CI = confidence interval


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