548 COMPARISON OF FREQUENTLY USED ACTIVE SURVEILLANCE CRITERIA IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY ON BASIS OF THE PATHOLOGIC FINDINGS FROM THE PROSTATECTOMY SPECIMENS

Vol. 189, No. 4S, Supplement, Sunday, May 5, 2013

547 A NATIONAL SURVEY OF RADIATION ONCOLOGISTS AND UROLOGISTS ON ACTIVE SURVEILLANCE FOR LOW-RISK PROSTATE CANCER Simon Kim*, R. Jeffrey Karnes, Rochester, MN; Paul Nguyen, Boston, MA; Bradley Leibovich, Rochester, MN; Jeanette Ziegenfuss, Minneapolis, MN; R. Houston Thompson, Stephen Boorjian, Leona Han, Jon TIlburt, Rochester, MN INTRODUCTION AND OBJECTIVES: While active surveillance (AS) is well recognized as an acceptable treatment strategy for low-risk prostate cancer (PC), the extent to which radiation oncologists and urologists perceive AS as effective and routinely recommend it to patients is unknown. Therefore, we sought to assess the attitudes and treatment recommendations for low-risk PC from a national survey of PC specialists. METHODS: A mail survey was sent to a population-based sample of 1,439 physicians in the U.S. from late 2011 and early 2012. Physicians were queried about their attitudes regarding AS and treatment recommendations for patients diagnosed with low-risk PC (PSA⬍10 ng/dl; T1c; and Gleason 6). Pearson Chi-square and multivariate logistic regression were used to test for differences in attitudes and treatment recommendations by physician demographics, compensation structure, primary place of employment, and specialty. RESULTS: Overall, 362 radiation oncologists and 360 urologists completed the survey for a 52% response rate. Most physicians reported that AS is effective for low-risk PC (72%) and stated that they were comfortable routinely recommending AS (69%). Urologists were more likely to agree that AS is effective (78% vs. 65%; p⬍0.001) and were comfortable recommending AS (75% vs. 62%; p⬍0.001) compared with radiation oncologists. Most physicians recommended radical prostatectomy (44%) or radiation therapy (32%), but fewer endorsed AS (22%) for low-risk disease. After adjusting for physician covariates, radiation oncologists were more likely to recommend radiation therapy (OR: 10.68; p⬍0.001), while urologists were more likely to recommend surgery (OR: 4.03; p⬍0.001) and AS (OR: 2.49; p⫽0.001) for low-risk PC. CONCLUSIONS: Although AS is widely viewed as effective by both radiation oncologists and urologists, most urologists continue to recommend surgery, while most radiation oncologists recommend radiation therapy. Our results may explain in part the relatively low contemporary use of AS in the U.S. Source of Funding: Informed Medical Decisions Foundation

548 COMPARISON OF FREQUENTLY USED ACTIVE SURVEILLANCE CRITERIA IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY ON BASIS OF THE PATHOLOGIC FINDINGS FROM THE PROSTATECTOMY SPECIMENS Andre Kavran*, Inga Kunz, Ulla Roggenbuck, Michaela Vanberg, Virgilijus Klevecka, Michael Musch, Darko Kroepfl, Essen, Germany INTRODUCTION AND OBJECTIVES: There is still no agreement on the most appropriate criteria for defining patients with prostate cancer (PCA) eligible for active surveillance (AS). Thus, we compared frequently used AS criteria in patients undergoing radical prostatectomy (RP) on basis of the pathologic findings from the RP specimens. METHODS: Between 06/1997 and 09/2011 2391 consecutive patients underwent RP in our institution. Of these patients only 451 (19%) (RP between 12/2000 and 09/2011) had at least a systematic 12-core biopsy and a sufficiently detailed pathologic report including number of tumor-positive cores, total number of cores taken, and primary and secondary biopsy Gleason grade. Using seven very common AS criteria these 451 patients were sub-divided in patients considered suitable and unsuitable for AS. Then both groups were analyzed on basis of the pathologic findings from the RP specimens. RESULTS: The median patient age was 66 years, the median preoperative PSA 7.8 ng/mL (median PSA density 0.13 ng/mL/mL),

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and the median number of biopsy cores taken 12. There were 298 (66%) cT1c, 87 (19%) cT2a, 59 (13%) cT2b/c, and 7 (2%) cT3 tumors. The biopsy Gleason score was ⬍⫽6 in 320 (71%) and ⬎⫽7 in 130 (29%) cases. Pathology of the RP specimens revealed 286 (63%) pT2, 118 (26%) pT3a, 35 (8%) pT3b, 12 (3%) pT4a, and 42 (9%) pN1 PCA with Gleason scores 5-6 in 239 (53%), 7a in 124 (27%), 7b in 28 (6%), and 8-10 in 60 (13%) cases. 192 (43%) patients showed a constellation of pT2a-c and Gleason Score ⬍⫽3⫹3 and pN0 potentially justifying AS. Depending on the criteria chosen 25-55% of patients would have been deemed eligible for AS. However, 31-43% of them harbored significant tumors (i.e. pT3a-4a or Gleason score ⬎⫽7a or pN1) with definitely unfavorable tumor characteristics (i.e. pT3b-4a or Gleason score ⬎⫽7b or pN1) in 8-11% of cases. Sensitivity and specificity of the different criteria ranged from 73% and 58% to 41% and 86%, respectively. CONCLUSIONS: Depending on the criteria used patients deemed eligible for AS harbored significant PCA in 31-43% of cases. At least in that 8-11% of patients with definitely unfavorable tumor characteristics AS with deferred treatment would have posed the risk of systemic disease progression. Source of Funding: None

549 EXTERNAL DIAGNOSTIC PROSTATE BIOPSY IN ACTIVE SURVEILLANCE: A PREDICTOR OF RE-CLASSIFICATION ON CONFIRMATORY BIOPSY Lih-Ming Wong*, Sarah Ferrara, Andrew Evans, Theo Van der Kwast, Greg Trottier, Narhari Timilshina, Ants Toi, John Trachtenberg, Girish Kulkarni, Robert Hamilton, Alexandre Zlotta, Neil Fleshner, Antonio Finelli, Toronto, Canada INTRODUCTION AND OBJECTIVES: In active surveillance (AS) for prostate cancer, we examine if having an externally performed diagnostic biopsy, compared to an in-house biopsy, predicts re-classification on the 2nd, otherwise known as the confirmatory, biopsy (B2). METHODS: We identified patients on AS from the database of our tertiary care referral centre (1997-2012) with PSA ⬍20, Gleason sum (GS) ⱕ6, stage T1c, ⱕ3 positive cores (PCore) for cancer, ⬍50% of single core involved, ageⱕ75y years and a repeat biopsy within 48 months after the initial biopsy. Patients were dichotomized on the basis of where their diagnostic biopsy (B1) was performed to internal (inhouse) or external. All externally taken biopsies were reported externally. For all patients, B2 was performed internally. Comparison of the internal and external groups, examining both B1 and B2, were made using the Mann-Whitney U and chi-squared tests. Logistical regression was used to assess if having the B1 performed externally was a predictor of re-classification at B2. RESULTS: A total of 649 patients were included, divided into external (n⫽138) and internal biopsy groups (n⫽511). Baseline age, PSA and prostate volume were similar between the groups. At baseline, patients with externally taken biopsies had more HGPIN (p⫽0.01) and ASAP (p⫽0.001) diagnosed, and less identification of TRUS nodules (p⫽0.001). The total number of cores taken at B1 was not statistically different between internal and external biopsy groups (p⫽0.07), however the internal group tended to have more cores taken. At B2, patients with external B1, compared to internal, had increases in all 3 pathological re-classification criteria: GSⱖ7 (24.6% versus 11.6%, p⫽0.001), PCore ⬎3 (23% versus 11.7%, p⫽0.001) and highest % core involved ⱖ50% (18.5% versus 8.3%, p⫽0.006). They were also more likely to have a TRUS nodule seen on B2 (45.5% versus 32.5%, p⫽0.003). Predictors of re-classification at B2 are shown in Table 1. CONCLUSIONS: At our institution, patients who had their initial diagnostic prostate biopsy performed externally are more likely to have adverse pathological features and re-classify on internal re-biopsy. Given these findings, this group of patients could be prioritized for earlier confirmatory biopsy.