Differences in Upgrading of Prostate Cancer in Prostatectomies between Community and Academic Practices

Objective. To determine whether initial biopsy performed by community or academic urologists affected rates of Gleason upgrading at a tertiary referral center. Gleason upgrading from biopsy to radical prostatectomy (RP) is an important event as treatment decisions are made based on the biopsy score. Materials and Methods. We identified men undergoing RP for Gleason or disease at a tertiary care academic center. Biopsy performed in the community was centrally reviewed at the academic center. Multivariate logistic regression was used to determine factors associated with Gleason upgrading. Results. We reviewed 1,348 men. There was no difference in upgrading whether the biopsy was performed at academic or community sites (OR 0.9, 95% CI 0.7–1.2). Increased risk of upgrading was seen in those with >1 positive core, older men, and those with higher PSAs. Secondary pattern 4 and larger prostate size were associated with a reduction in risk of upgrading. Compared to the smallest quartile of prostate size (<35？g), those in the highest quartile (>56？g) had a 49% reduction in risk of upgrading (OR 0.51, 95% CI 0.3–0.7). Conclusion. There was no difference in upgrading between where the biopsy was performed and community and academic urologists. 1. Introduction Prostate cancer risk stratification prior to definitive treatment is crucial as treatment selection relies on these factors. Whereas the PSA and clinical stage can be easily repeated with minimal patient risk, repeating the prostate needle biopsy to confirm accurate Gleason grading is much more invasive. Thus, adequate sampling of the prostate during biopsy is paramount. Despite improvements in sampling techniques at prostate needle biopsy, discordance between the diagnostic biopsy Gleason score and radical prostatectomy (RP) Gleason score occurs in up to 40% of the cases [1]. Several factors are associated with an increased risk of pathologic upgrading. These include smaller prostates [2, 3], higher PSAs [3, 4], and higher volume cancer at biopsy [5]. In addition, interobserver variability in pathologic interpretation of PCa specimens plays a role in this discordance [6–8]. Central pathologic review by dedicated genitourinary pathologists has been shown to lead to more accurate grading of the biopsy Gleason score and subsequent higher concordance with RP Gleason score [9]. It is now common for tertiary centers to require internal review of all outside biopsies prior to treatment. Several technical aspects to improve prostate sampling have been instituted including laterally directed biopsies [10], increased