High-risk prostate cancer (HRPCa) is associated with a significant risk of recurrence after radical treatment. While several classification systems exist, the D’Amico criteria – based on clinical T stage ≥T2c, prostate specific antigen (PSA) ≥20 ng/mL, or Gleason score (GS) ≥8 – are widely adopted in guidelines by the European Association of Urology (EAU), American Urological Association (AUA), and the National Institute for Health & Care Excellence (NICE). Radical prostatectomy (RP) is a common treatment option, but biochemical recurrence (BCR) occurs in 20–40% of cases, often necessitating a multimodality approach involving radiotherapy and hormone therapy. This study focused on evaluating pre-surgical risk factors – PSA, GS, and T stage – to better predict BCR and guide initial treatment decisions. It was found that PSA ≥20ng/mL or GS ≥8 significantly increased the risk of BCR, with multiple risk factors posing even greater threats. Interestingly, PSA was a more reliable predictor of BCR than GS when analysed independently. However, GS ≥8 gained significance when combined with T stage ≥T2c. A patient-friendly nomogram was developed to assist in counselling by predicting BCR risk using these pre-surgical factors. Post-surgical variables like tumour density >25%, positive surgical margins, and lymph node involvement also correlated with BCR, but not all such cases progressed to recurrence. Notably, pelvic lymph node dissection (PLND) rates varied despite guideline recommendations, influenced by surgeon discretion and preoperative risk assessment. Most BCR cases occurred within three years post-surgery, supporting the need for close early surveillance. Although RP use is rising, no consensus exists on the ideal multimodal treatment strategy. Limitations of this study include the lack of comparison with external beam radiation therapy (EBRT) outcomes and variation in HRPCa definitions. Emerging imaging technologies like prostate-specific membrane antigen (PSMA) positron emission tomography (PET) and AI-based tools may enhance future risk assessment and treatment planning. Pre-surgery risk stratification remains crucial in guiding patient choices and anticipating multimodal therapy needs.
Preoperative risk stratification of high-risk prostate cancer patients
Reviewed by Asif H Ansari
Pre-operative risk stratification of high-risk prostate cancer patients can predict risk of biochemical recurrence for individual patients post radical surgery: A multi-institutional study.
