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.
| Variable | HR (95% CI) | p value |
| Insurance Status | ||
| Uninsured (base) | (reference) | |
| Private insurance/Managed care | 0.72 (0.66-0.78) | <0.001 |
| Medicaid | 1.13 (1.03-1.25) | 0.012 |
| Medicare | 0.90(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) | |
| 2011 | 1.07 (1.04-1.11) | <0.001 |
| 2012 | 1.07 (1.03-1.10) | <0.001 |
| 2013 | 1.13 (1.08-1.17) | <0.001 |
| 2014 | 1.19 (1.14-1.24) | <0.001 |
| 2015 | 1.17 (1.11-1.23) | <0.001 |
| Age | 1.05 (1.05-1.07) | <0.001 |
| Median Income Quartiles (2012-2016) | ||
| <$40,227 (base) | (reference) | |
| $40,227-50,353 | 0.86 (0.84-0.89) | <0.001 |
| $50,354-63,332 | 0.82 (0.79-0.85) | <0.001 |
| >=$63,333 | 0.71 (0.68-0.74) | <0.001 |
| Charlson-Deyo Score | ||
| 0 (base) | (reference) | |
| 1 | 1.45 (1.41-1.49) | <0.001 |
| 2 | 2.15 (2.05-2.25) | <0.001 |
| 3 | 2.86 (2.66-3.07) | <0.001 |
| Facility Type | ||
| Community Cancer Program (base) | (reference) | |
| Comprehensive Community Cancer Program | 0.95 (0.91-0.98) | 0.003 |
| Academic/Research Program | 0.79 (0.76-0.82) | <0.001 |
| Integrated Network Cancer Program | 0.93 (0.89-0.97) | <0.001 |
| Risk Category | ||
| Low (base) | (reference) | |
| cT2b-c, GG1, PSA <10 | 1.10 (1.10-1.22) | 0.070 |
| Favorable intermediate | 1.36 (1.32-1.41) | <0.001 |
| Unfavorable intermediate | 1.60 (1.58-1.70) | <0.001 |
| cT2b-c, GG1, PSA 10-20 | 1.83 (1.49-2.25) | <0.001 |
| High | 2.52 (2.45-2.60) | <0.001 |
| Risk Category | ||
| Low | 0.61 (0.59-0.63) | <0.001 |
| cT2b-c, GG1, PSA <10 | 0.67 (0.61-0.75) | <0.001 |
| Favorable intermediate | 0.83 (0.80-0.86) | <0.001 |
| Unfavorable intermediate (base) | (reference) | |
| cT2b-c, GG1, PSA 10-20 | 1.10 (0.91-1.37) | 0.285 |
| High | 1.54 (1.49-1.59) | <0.001 |
| Treatment Type | ||
| No treatment (base) | (reference) | |
| Surgery alone | 0.31 (0.30-0.32) | <0.001 |
| Radiation alone | 0.56 (0.55-0.58) | <0.001 |
| Surgery and radiation | 0.45 (0.42-0.48) | <0.001 |
| HR = hazard ratio; CI = confidence interval |
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