Does active surveillance prior to radical prostatectomy increase the risk of adverse pathological findings or postoperative prostate cancer treatment?

Abstract

Active surveillance (AS) is an established management strategy for men with low- and favorable intermediate-risk prostate cancer (PCa). Nevertheless, a substantial proportion of patients ultimately undergo radical prostatectomy (RP), and the impact of prior AS on subsequent outcomes remains uncertain. We therefore compared surgical methods, adverse pathological findings and post-RP PCa-treatment among men undergoing deferred RP after AS with those of comparable men treated with immediate RP. Using nationwide data from the Norwegian Prostate Cancer Registry, we identified men diagnosed between 2009 and 2022 with low- or intermediate-risk PCa who underwent deferred RP following AS or immediate RP. Descriptive statistics summarized clinical characteristics and surgical methods. Multivariable logistic regression evaluated adverse pathological findings in the surgical specimen, and Cox proportional hazards models analyzed post-RP PCa-treatment. Kaplan-Meier analyses with log-rank test assessed 10-year PCa-specific survival. Compared with immediate RP (n = 5767), the deferred RP (n = 1839) group had more unfavorable preoperative tumor characteristics, fewer nerve-sparing procedures and more frequent lymph node dissection. Deferred RP after AS was associated with higher risk of adverse pathological findings (OR 1.99, 95% CI 1.8–2.3) and post-RP PCa-treatment (HR 1.52, 95% CI 1.3–1.8). Ten-year PCa-specific survival did not differ between groups. Limitations include incomplete data on surveillance intensity. Deferred RP after AS was associated with more extensive surgery, adverse pathological findings and post-RP PCa-treatment, but similar ten-year PCa-specific survival, compared to immediate RP. These findings emphasize the need for surveillance strategies that ensure timely detection of disease progression and transition to radical treatment.