Association of Age with Risk of Adverse Pathological Findings in Men Undergoing Delayed Radical Prostatectomy Following Active Surveillance

The treatment paradigms for prostate cancer have drastically changed over the past decade. Nowadays most low-grade cancers are monitored with active surveillance and curative therapies are deferred until there is evidence of disease progression. The patients enrolled in active surveillance protocols need to be carefully selected and closely monitored however so that oncologic outcomes are not affected. Defining what constitutes an appropriate active surveillance candidate and then how to best surveil the patients is still a matter of debate. It is unclear how patient age should factor into active surveillance candidacy and protocols.

Previous studies have shown that prostate cancer is more aggressive and has worse outcomes in older men. Older men are also known to be at higher risk of being upgraded on active surveillance. To better understand the importance of age on active surveillance candidacy, we aimed to determine the impact of older age on the risk of adverse pathology after delayed radical prostatectomy among men with Gleason grade group (GG) 1 prostate cancer initially managed with active surveillance, comparing men <65 years to the men ≥65 years. We found that the older men had higher upgrade rates, they spent less time on active surveillance, they had more adverse pathology at radical prostatectomy, and older age was associated with adverse pathology at radical prostatectomy. In the older group, MRI was also a predictor of adverse pathology but a composite genomic classifier score we generated from three commercially available tests was not.

The study is limited by a lack of uniformity in surveillance protocols and of the testing obtained while on active surveillance. Not all patients had MRIs or genomic testing for example, which could explain our findings. This study does show however that older aged patients with GG1 prostate cancer might harbor more aggressive disease than their younger counterparts with initially similar clinical parameters. Further studies are needed to better understand which patients can be safely monitored on active surveillance and the role of MRI and genomic testing in the decision-making process.

Written by: Claire de la Calle, MD, Urology Resident, University of California San Francisco

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