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Revisiting current National Comprehensive Cancer Network (NCCN) high-risk prostate cancer stratification: a National Cancer Database analysis



High-risk prostate cancer includes heterogenous populations with variable outcomes. This study aimed to compare the prognostic ability of individual high-risk factors, as defined by National Comprehensive Cancer Network (NCCN) risk stratification, in prostate cancer patients undergoing radical prostatectomy.


We queried the National Cancer Database from 2004 to 2018 for patients with non-metastatic high-risk prostate cancer who underwent radical prostatectomy and stratified them as Group H1: Prostate specific antigen (PSA) > 20 ng/ml alone, Group H2: cT3a stage alone and Group H3: Gleason Grade (GG) group 4/5 as per NCCN guidelines. The histopathological characteristics and rate of adjuvant therapy were compared between different groups. Inverse probability weighting (IPW)-adjusted Kaplan–Meier curves were utilized to compare overall survival (OS) in group H1 and H2 with H3.


Overall, 61,491 high-risk prostate cancer patients were identified, and they were classified into Group H1 (n = 14,139), Group H2 (n = 2855) and Group H3 (n = 44,497). Compared to group H1 or H2, pathological GG group > 3 (p < 0.001), pathological stage pT3b or higher (p < 0.001), lymph nodal positive disease (pN1) (p < 0.001) and rate of adjuvant therapy (p < 0.001) were significantly in Group H3. IPW-adjusted Kaplan–Meier curves showed significantly better 5-year OS in group H1 compared to group H3 [95.1% vs 93.3%, p < 0.001] and group H2 compared to group H3 [94.4% vs 92.9%, p < 0.001].


PSA > 20 ng/ml or cT3a stage in isolation have better oncologic and survival outcomes compared to GG > 3 disease and sub-stratification of ‘High-risk’ category might lead to better patient prognostication.

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Fig. 1: Overall survival analysis in patients with high-risk prostate cancer.

Data availability

The data is available from the corresponding author on request.


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Authors and Affiliations



HG- Investigation, visualization, Data curation, Data analysis, writing – original draft. FD- Investigation, visualization, Writing - Review & Editing. FA- Investigation, visualization, Writing - Review & Editing. HW- Data analysis, visualization, Writing - Review & Editing. SW- Data analysis, Visualization, ML- Investigation, visualization, Writing - Review & Editing. DK- Investigation, visualization, Writing - Review & Editing. RSS- Investigation, Writing - Review & Editing. AMM- Conceptualization, Methodology, Writing – review and editing, Supervision, Project administration.

Corresponding author

Correspondence to Ahmed M. Mansour.

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The authors declare no competing interests.

Ethical approval and consent to participate

The study was done in accordance with the Declaration of Helsinki. It is a retrospective analysis of National Cancer Database and the need for informed consent was waived in view of anonymity of the data. The National Cancer Data Base (NCDB) is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The CoC’s NCDB and the hospitals participating in the CoC NCDB are the source of the de-identified data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

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Garg, H., Dursun, F., Alsayegh, F. et al. Revisiting current National Comprehensive Cancer Network (NCCN) high-risk prostate cancer stratification: a National Cancer Database analysis. Prostate Cancer Prostatic Dis (2023).

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