Upgrading and upstaging at radical prostatectomy in the post-prostate-specific antigen screening era: an effect of delayed diagnosis or a shift in patient selection?

Prostate cancer management changed in recent times given the recommendation against prostate-specific antigen screening, adherence to active surveillance, and “cytoreductive” surgery. We hypothesized that radical prostatectomy (RP) findings changed as well. All consecutive RPs (n = 1348) and first time prostate needle biopsies (n = 1719) in a period of 9 years were reviewed. The cohort was separated into 3 groups: (1) from May 2006 to April 2009, (2) from May 2009 to April 2012, and (3) from May 2012 to April 2015. The number of RPs decreased 15% from 551 in group 1 to 476 in group 2 and decreased a further 35% to 311 in group 3. Pure Gleason 6 (grade group 1) decreased from 46% in group 1 to 24% in group 2 (P < .001) to 12% in group 3 (P < .001). Gleason score 4 + 3 = 7 (grade group 3) increased from 9.8% in group 1 to 13.4% in group 2 (P = .07) to 20.6% in group 3 (P = .01). Gleason score 8, 9, or 10 (grade groups 4 and 5) increased from 0.9% in group 1 to 8.4% in group 2 (P < .001) to 13.2% in group 3 (P = .04). Pathologic stage pT3 or above increased from 15.5% in group 1 to 29.2% in group 2 (P < .01) to 38.3% in group 3 (P = .01). In needle biopsies, there was no difference in number of cancer diagnoses, number of positive cores, or distribution of grades among 3 groups. More patients with low-risk disease are opting for active surveillance, and patients with high-risk disease are offered cytoreductive surgery. Lack of similar changes in needle biopsies suggests that a decrease in screening is not playing a role in the changes seen at RPs.