Clinical and racial predictors of adverse pathology at radical prostatectomy: implications for undertreatment among patients receiving radiation and hormonal therapy

Mutlay Sayan^1,*, Yetkin Tuac², Zhiyu Qian^3,4, Alexander P. Cole^3,4, Jonathan E. Leeman¹, Martin T. King¹, Paul L. Nguyen¹, Anthony V. D’Amico¹
1 Department of Radiation Oncology, Brigham and Women’s Hospital and Dana Farber Cancer Institute, Boston, MA, USA
2 Department of Statistics, Ankara University, Ankara, Türkiye
3 Department of Urology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
4 Center for Surgery and Publlic Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
* Corresponding Author: Mutlay Sayan. Email: email

Canadian Journal of Urology https://doi.org/10.32604/cju.2026.074677

Received 15 October 2025; Accepted 09 January 2026; Published online 18 February 2026

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Abstract

Objectives: Under-grading exists in up to 7% of patients undergoing radical prostatectomy (RP) for prostate cancer (PC). We assessed whether underrepresented race and ethnicity disproportionately increased the odds of adverse pathology at RP in patients with biopsy Gleason score 6 or 7 PC at high-risk for upgrading and/or upstaging at RP based on age and PC indices at presentation. Methods: This retrospective cohort study analyzed 76,474 patients in the National Cancer Database (2015–2021) with biopsy Gleason score 6 or 7 N0M0 PC. Odds ratio (OR) at RP of adverse pathology defined as prostatectomy (p) Gleason score 9–10, node-positive disease, or pT3b-T4 PC in patients at high- or highest-risk for upgrading at RP. The highest-risk group comprised age > 70 years, PSA > 10 ng/mL, cT2 or higher, ≥50% positive biopsy cores, and Black or other non-White race and/or Hispanic ethnicity versus the same clinical factors and White race and non-Hispanic ethnicity for high-risk. Others were classified as low-risk. Results: The adverse pathology OR was 4.36 (95% CI, 3.10–6.89), and 2.64 (95% CI, 2.25–3.08) for patients in the high-risk and highest-risk groups respectively compared to low-risk. Highest-risk patients had a significantly higher adverse pathology OR [1.70 (95% CI, 1.11–2.60); p = 0.015] when compared to high-risk patients. Conclusions: Disproportionate under-grading and under-staging observed in under-represented minorities can lead to under-treatment in the highest-risk patients electing to undergo radiation and androgen deprivation therapy (ADT), given ADT duration could be based on under-graded PC, highlighting the urgent need to improve the detection strategy in these patients.