Introduction: With the burden of evidence that exists supporting active surveillance of grade group 1 prostate cancer, radical prostatectomy as the primary management of these patients is becoming less frequent however in the UK 11% of radical prostatectomies are still for grade group 1 disease. Reasons that this cohort of patients are offered surgery include: patient choice, disease progression or the presence of risk factors. What are the outcomes for these patients, and ultimately is surgical treatment in this group justified?
Methods: We retrospectively analysed our cohort of 972 radical prostatectomies between 2015-2021 for biopsy proven grade group 1 prostate cancer looking at histopathological concordance and long-term outcomes.
Results: In total 64 (6.6%) patients were grade group 1 on prostate biopsy. The average age was 61 years (SD+/-10), the average PSA was 6.8 ng/ml (SD+/-5.1). All patients were either ASA 1 or 2. 51 patients (79.7%) were low-risk as per the D’Amico classification, 7 were intermediate-risk (10.9%) and 6 were high-risk (9.4%). The overall rate of pathological upgrade from grade group 1 was 81%. The positive margin rate was 18.7%.
21 patients (32.8%) had radical prostatectomy primarily due to patient choice, 43 (67.2%) had a variety of other clinical reasons including: pathological or imaging progression, high volume of disease or a strong family history of prostate cancer.
40 patients underwent primary surgery without surveillance with an upgrade rate of 87.5%. 22 patients converted to radical prostatectomy following active surveillance for an average of 2.7 years with an upgrade rate of 72.7%.
Overall 60.4% patients had either grade group 1 or 2 (less than 5% pattern 4) on their final histology, with 39.6% having grade group 2 (more than 5% pattern 4) or 3. There was no significant difference when differentiating for patient choice or other clinical reasons. The number needed to treat was 2.5.
Only one patient has required salvage radiotherapy till date (1.6%).
Conclusions: Performing radical surgery on grade group 1 disease remains contentious. A combination of features prompt surgery in a select proportion of these patients, and a near 40% upgrade rate remains significant. As there has not been a single parameter that has been established as the best clinical indicator for performing radical prostatectomy, the decision to offer surgery in these patients remains a clinical decision.
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