Objectives
To characterize the clinical progression of disease in men who have undergone prostatectomy
for clinically localized prostate cancer and have postoperative biochemical failure
(elevated prostate-specific antigen [PSA] level) and to identify predictors of clinical
disease progression, including the possible effect of PSA doubling time (PSADT).
Patients and Methods
Between 1987 and 1993, 2809 patients underwent radical retropubic prostatectomy for
clinically localized (≤T2) disease. In our database, all patients with postoperative
biochemical failure (PSA level ≥0.4 ng/mL) were identified. The PSADT was estimated
using log linear regression on all PSA values (excluding those values determined after
administration of hormonal therapy) within 15 months after biochemical failure. All
patients had regular PSA measurements from the time of surgery through the follow-up
period. Systemic progression (SP) was defined as evidence of metastatic disease on
a bone scan. Local recurrence (LR) was defined on the basis of digital rectal examination,
transrectal ultrasonography, and biopsy. The SP-free survival and LR/SP-free survival
(survival free of both LR and SP) after biochemical failure was estimated with use
of the Kaplan-Meier method. Patients with prostate cancer treatment after biochemical
failure had their follow-up censored from this study at the time of treatment.
Results
Postoperative biochemical failure occurred in 879 men (31%). The mean follow-up from
time of biochemical failure was 4.7 years (range, 0.5–11 years). The mean time to
biochemical failure was 2.9 years (median, 2.4 years). The overall mean SP-free survival
from time of biochemical failure was 94% and 91% at 5 and 10 years, respectively.
The mean LR/SP-free survival was 64% and 53% at 5 and 10 years, respectively. By using
univariate analysis on the 587 patients with PSADT data, significant risk factors
for SP were PSADT (P<.001) and pathologic Gleason score (P=.005); for LR/SP, significant risk factors included PSADT (P<.001) and pathologic Gleason score (P<.001). In multivariate Cox models analysis, only PSADT remained a significant risk
factor for both SP and LR/SP (P<.001). Mean 5-year SP-free survival was 99%, 95%, 93%, and 64% for patients with
PSADT of 10 years or longer, 1.0 to 9.9 years, 0.5 to 0.9 year, and less than 0.5
year, respectively; the respective mean LR/SP-free survivals were 87%, 62%, 46%, and
38%. The percentage of patients with PSADT of less than 0.5 year was considerably
higher if the type of first clinical event was SP (48%) compared with LR (18%) (P<.001).
Conclusions
For patients who have undergone radical prostatectomy, a rising PSA level suggests
evidence of residual or recurrent prostate cancer. Many men remain free of clinical
disease for an extended time after biochemical failure following radical prostatectomy
for clinically localized prostate cancer. The PSADT appears to be an important predictor
of SP and also of any clinical progression (local or systemic). These data may be
useful when counseling men regarding the timing of adjuvant therapies.
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Article info
Footnotes
Dr Roberts is now with Urology Associates, Scottsdale, Ariz.
Identification
Copyright
© 2001 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- The Utility of PSA Doubling Time to Monitor Prostate Cancer RecurrenceMayo Clinic ProceedingsVol. 76Issue 6
- PreviewOne of the most challenging issues in prostate cancer diagnosis and treatment is the determination of which patients have clinically important tumors. This issue is relevant not only in men with newly diagnosed tumors, but also in men whose disease recurs after primary treatment for prostate cancer. Specifically, it is important to segregate patients with “low-risk” cancers that can be observed from patients with “high-risk” cancers that may benefit from early treatment. To stratify patients by risk, researchers have used tumor grade, tumor stage, prostate-specific antigen (PSA) level, and radiographic studies such as endorectal magnetic resonance imaging, immunoscintigraphic scanning, and positron emission tomography.
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