Evaluating the rates of surgical overtreatment of prostate cancer.
Authors: Monda Steven , Demus Timothy , Meah Sabir , Srivastava Arnav , Sarle Richard , Ginsburg Kevin , Morgan Todd Matthew , Borza Tudor 
Published: February 2025

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Background:
Overtreatment of prostate cancer is a public health concern and a barrier to prostate cancer screening. In 2012 the US Preventative Task Force (USPTF) recommended against PSA screening citing overtreatment of indolent disease, and its associated morbidity, as a major limitation to the safety of widespread screening. In 2018 the USPTF updated their recommendation to PSA screening should only be pursued after an individualized discussion with the patient, emphasizing the risk of overtreatment. We sought to evaluate the rates of surgical overtreatment of prostate cancer over the last two decades.
Methods:
We evaluated the proportion of radical prostatectomies (RP) with pathologic Grade Group 1 (pGG1), as a surrogate for clinically insignificant disease, between 2012 and 2024 within the Michigan Urological Surgery Improvement Collaborative (MUSIC) and between 2010 and 2020 within the Surveillance Epidemiology and End Results (SEER) registry. MUSIC served as a statewide sample with a focus on urology outcomes, while SEER served as a national sample. Within MUSIC, pGG1, as a binary variable, was modeled in a mixed effects logistic model, against time while controlling for preoperative PSA, age, race, proportion and number of biopsy cores positive, and biopsy grade. We also assessed the proportion of these pGG1 RPs with preoperative higher-risk features: PSA ≥10, >50% of biopsy cores positive, or clinical Grade Group 2 on biopsy. Presence of any of these risk features was modeled as a binary variable against time, controlling for age and race.
Results:
Among 23,370 RPs in MUSIC and 162,558 RPs in SEER, the proportion of pGG1 decreased over the time periods examined. The proportion of patients undergoing RP with pGG1 on final pathology decreased from 21% to 2.7% from 2012 to 2024 within MUSIC and decreased from 32% to 7.8% from 2010 and 2020 within SEER. Within MUSIC, time was independently associated with a decrease in the proportion of RPs that were pGG1 (OR 0.52 per 5-years, 95% CI 0.47-0.57). During these time periods, the proportion of patients undergoing pGG1 RP with preoperative PSA ≥10 increased from 6.0% to 13% within MUSIC and increased from 8.1% to 10% within SEER. The proportion of pGG1 RPs with >50% cores positive on preoperative biopsy increased from 3.6% to 19% within MUSIC and from 11.8% to 15% within SEER. Time was independently associated with an increase in the proportion of pGG1 RP that had any pre-operative higher-risk features (OR 2.25 per 5 years, 95% CI 2.07-2.46).
Conclusions:
The rate of surgical overtreatment of low-risk prostate cancer has profoundly declined over the last two decades. A lower proportion of RPs are pGG1 and the pGG1 RPs being performed are more likely to have higher-risk preoperative features.

Proportion of prostatectomies that were pGGG1.

2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024

MUSIC
-
-
21%
18%
19%
16%
12%
8.4%
8.4%
7.2%
5.5%
5.6%
5.5%
3.7%
2.7%

SEER
32%
31%
26%
23%
20%
16%
13%
11%
10%
8.8%
7.8%
-
-
-
-