JU INSIGHT: Gleason Grade 1 Prostate Cancer Volume at Biopsy Is Associated With Upgrading but Not Adverse Pathology or Recurrence After Radical Prostatectomy: Results From a Large Institutional Cohort

By: Kevin Shee, MD, PhD; Samuel L. Washington III, MD, MAS; Janet E. Cowan, MA; Claire M. de la Calle, MD; Avi S. Baskin, MD, MPhil; Meera R. Chappidi, MD, MPH; Domenique Escobar, MD; Hao G. Nguyen, MD, PhD; Matthew R. Cooperberg, MD, MPH; Peter R. Carroll, MD, MPH | Posted on: 17 Jan 2023

Shee K, Washington SL III, Cowan JE, et al. Gleason grade 1 prostate cancer volume at biopsy is associated with upgrading but not adverse pathology or recurrence after radical prostatectomy: results from a large institutional cohort. J Urol. 2023;209(1):198-207.

Study Need and Importance

Active surveillance has been widely accepted as the standard management for low-risk prostate cancer (PCa), which is typically defined as low-grade (Gleason grade group 1 [GG1]), stage T1c or T2a, and PSA <10 ng/mL. However, there is controversy surrounding the appropriate clinical management of patients with high-volume, low-grade PCa. Risk stratification guidelines such as the National Comprehensive Cancer Network Guidelines suggest that patients with high-volume disease (>3 positive cores on biopsy) may benefit from definitive treatment such as radical prostatectomy (RP) or radiation therapy, although evidence for this statement is inconclusive.

Figure. Multivariable regression model results for pathological upgrade or adverse pathology and recurrence after radical prostatectomy for 1,029 men at University of California, San Francisco.

What We Found

Inclusion criteria were T1/T2 PCa, PSA at diagnosis <10 ng/mL, GG1, and management with primary RP. A total of 1,029 patients met inclusion criteria. Volume of PCa was defined by percentage of positive cores (PPC). Outcomes were pathological upgrade (≥GG2), UCSF (University of California, San Francisco) adverse pathology (≥GG3, pT3/4 or pN1), alternate adverse pathology (≥GG3, ≥pT3b, or pN1), and recurrence (biochemical failure with 2 PSA ≥0.2 ng/mL or salvage treatment) after RP. Multivariable logistic regression models demonstrated significant associations between PPC and pathological upgrade (OR 1.31, 95% CI 1.1-1.57, P < .01), but not UCSF adverse pathology at RP (P = .84); PPC was negatively associated with alternate adverse pathology (OR 0.67, 95% CI 0.48-0.93, P = .02). Multivariable Cox regression models demonstrated no association between PPC and hazard of recurrence after RP (P = .11). Multivariable regression analyses are summarized in the Figure.


Retrospective study, absence of uniform diagnostic or treatment protocol, low percentage of patients receiving prostate MRI, single institution.

Interpretation for Patient Care

Although increased volume of PCa was associated with pathological upgrade, it was not associated with adverse pathology or recurrence after RP in patients with low-risk PCa. Our findings question the influence of increased PCa volume on risk stratification and the decision to pursue definitive treatment over active surveillance in patients with high-volume, low-grade PCa.