Trends in Radical Prostatectomy Risk Group Distribution in a European Multicenter Analysis of 28 572 Patients: Towards Tailored Treatment

Background: Active surveillance (AS) has been increasingly proposed as the preferential initial management strategy for low-risk prostate cancer (PC), while in high-risk PC the indication for surgery has widened. Objective: To evaluate the development of risk group distribution of patients undergoing radical prostatectomy (RP). Design, setting, and participants: Retrospective database review of combined RP databases (2000-2015) of four large European centers (Créteil, Paris; San Rafaele, Milan; Martini Klinik, Hamburg; NKI, AvL, Amsterdam). Outcome measurements and statistical analysis: Clinical and pathological characteristics per year of surgery. Eligibility for AS was defined according to Prostate Cancer Research International Active Surveillance criteria: cT. ⠤. 2c, cN0/X, cM0/X, PSA ⠤10. ng/ml, prostate-specific antigen density <0.2. ng/ml/ml, one to two positive biopsies, and Gleason score ⠤6, high-risk disease as: cT. ⠥. 3, c N1, cM1, PSA >20. ng/ml, and/or Gleason ⠥8. Results and limitations: In total, 28. 572 patients had complete clinical and 24. 790 complete pathological data available. The absolute number of RPs increased: 401, 975, 2344, and 2504 in 2000, 2005, 2010, and 2015, respectively. The proportion of cases considered suitable for AS decreased: 31%, 32%, 18%, and 5%, while the cases considered high risk increased: 10%, 8%, 16%, and 30%. The percentage of patients having only localized Gleason 6 disease after RP decreased: 46%, 34%, 14%, and 8% for all patients (p< 0.01), as well as for AS-suitable patients: 70%, 54%, 41%, and 38% (p <. 0.01). Comparisons between centers were outside the scope of this article. Developments in diagnostics may have impacted on results. Conclusions: This European analysis confirmed the risk profile of patients undergoing RP shifting away of the most favorable disease spectrum. Patients with PC clinically considered suitable for AS and men having only localized Gleason 6 disease pathologically comprised a decreasing share of all RP performed. High-risk disease comprised an increasing share of all RPs. Patient summary: The databases of four large European centers of prostate cancer surgery were analyzed. In recent years, the risk profile of patients shifted away of low-risk cancer, while high-risk cancer comprised a larger part of cases. This confirms the introduction of active surveillance for low-risk prostate cancer and increase in potentially curative options for high-risk disease. Data from four large European radical prostatectomy centers confirm a shift away from surgery in patients clinically considered suitable for active surveillance and in patients with pathologically favorable disease. High-risk patients comprise an increasing share of all surgical cases.