Favorable Gleason 3 + 4 Prostate Cancer Shows Comparable Outcomes With Gleason 3 + 3 Prostate Cancer: Implications for the Expansion of Selection Criteria for Active Surveillance.

BACKGROUND: To investigate the feasibility of active surveillance (AS) in biopsy Gleason score (GS) 3 + 4 prostate cancer (PCa), we compared the outcomes of biopsy GS 3 + 3 and 3 + 4 PCa after radical prostatectomy.

PATIENTS AND METHODS: We analyzed the data of 1491 patients undergoing radical prostatectomy for biopsy GS 3 + 3 or 3 + 4 PCa who fulfilled the low-risk criteria of the National Comprehensive Cancer Network guidelines regardless of GS. The favorable GS 3 + 4 group was defined as having core involvement ≤ 50%, prostate-specific antigen density ≤ 0.2 ng/mL/cm3 , and number of positive cores ≤ 2 (maximal 1 core of GS 3 + 4).

RESULTS: The GS 3 + 4 group showed significantly worse pathologic outcomes, including pathologic GS, pathologic stage, and seminal vesicle invasion rate (all P < .001), as well as worse biochemical recurrence-free survival (P < .001) than the GS 3 + 3 group. However, the favorable GS 3 + 4 subgroup showed no significant differences in the pathologic outcomes (all P > .05) and in biochemical recurrence-free survival (P = .817) compared to the GS 3 + 3 group.

CONCLUSION: Despite the application of low-risk criteria, GS 3 + 4 PCa patients showed significantly worse outcomes than GS 3 + 3 patients. However, favorable GS 3 + 4 patients showed comparable clinicopathologic outcomes with GS 3 + 3 patients, suggesting possible expansion of AS for the favorable GS 3 + 4 group.