Epidemiology of radical prostatectomy for localized prostate cancer in the era of prostate-specific antigen: an overview of the Department of Defense Center for Prostate Disease Research national database

Prostate gland volume is a strong predictor of biopsy results in men 70 years or older with prostate-specific antigen levels of 2.0-10.0 ng/mL

PURPOSE

The incidence of prostate cancer, benign prostatic enlargement and serum level of prostate-specific antigen (PSA) increase with patient age. Intermediate elevation of PSA in elderly populations is apt to be considered insignificant. We evaluated the impact of PSA and prostate volume on the presence of non-palpable prostate cancer in elderly men with an intermediate level of PSA.

MATERIALS AND METHODS

Clinical records of 154 men 70 years or older, with non-cancerous digital rectal examination findings and with serum PSA levels of 2.0-10.0 ng/mL, who underwent initial 6- to 10-core transrectal prostate biopsy, were reviewed for prostate volume, number of biopsy cores, PSA and associated parameters. Stepwise logistic regression and receiver operating characteristic (ROC) models were used to determine the impacts of the parameters on the biopsy results.

RESULTS

Overall cancer detection rate was 40/154 or 26.0%. Prostate-specific antigen showed no significant association with the presence of prostate cancer (P = 0.59, Mann-Whitney U-test), while prostate volume did (P < 0.0001). On stepwise logistic regression analysis, prostate volume (P = 0.024, 95% CI 1.008-1.116) and biopsy core density (P = 0.017, 95% CI 4.76-7.12 x 10(6)) were independently associated with a cancer diagnosis, whereas PSA density was not an independent factor for a positive biopsy result. The area under the ROC curve for prostate volume was significantly superior to that of PSA (0.802 vs. 0.529; P = 0.012).

CONCLUSIONS

In men 70 years or older with gray zone PSA, prostate cancer patients are equally distributed over any PSA range. Although PSA has less impact on cancer presence than mere prostate volume, prostate cancer would be detected in a substantial proportion of older patients with PSA levels of 2.0-10.0 ng/mL.

Does year of radical prostatectomy independently predict outcome in prostate cancer?

OBJECTIVES

To examine how the biochemical outcomes after radical prostatectomy (RP) have changed in the prostate-specific antigen (PSA) era when controlling for the effects of other prognostic variables. Since the beginning of the PSA era, the presentation, treatment, and therapeutic outcomes of prostate cancer have evolved.

METHODS

We reviewed the Columbia University Comprehensive Urologic Oncology Database and identified 1319 patients who had undergone RP without adjuvant therapy, performed by three surgeons, between 1988 and 2003 (minimal follow-up of 12 months). Univariate Cox proportional hazards models were used to determine which variables affect the hazard of biochemical failure (BCF), defined as a PSA level of 0.2 ng/mL or greater on at least two occasions, after RP. Multivariate analysis, controlling for the effects of other prognostic variables, was used to determine the effect that the year of surgery had on hazard of BCF.

RESULTS

Univariate analysis confirmed the importance of the year of surgery, preoperative PSA level, pathologic stage, Gleason sum, and surgical margin status in estimating the hazard of BCF (P <0.001). Age at surgery did not have a statistically significant effect. A multivariate Cox model showed that the year of surgery had a highly significant impact on the hazard of BCF even when controlling for PSA, stage, Gleason sum, and surgical margin status.

CONCLUSIONS

Patients undergoing RP in more recent years are at significantly less risk of BCF compared with patients who underwent surgery earlier in the PSA era, even when controlling for the effects of other prognostic variables. The factors that account for this change in outcomes over time have yet to be identified.

Prostate-specific antigen versus prostate-specific antigen density as predictor of tumor volume, margin status, pathologic stage, and biochemical recurrence of prostate cancer

OBJECTIVES

To compare prostate-specific antigen (PSA) and PSA density (PSAD) calculated by transrectal ultrasound (TRUS) volume (TRUS PSAD), pathologic volume (Path PSAD), and weight (Weight PSAD) for their ability to predict pathologic characteristics and biochemical recurrence of prostate cancer. We also compared all PSAD derivatives to determine consistency.

METHODS

Between 1993 and 2002, 306 patients were retrospectively identified who had had PSAD determined preoperatively by TRUS and subsequently underwent radical prostatectomy with whole mounting and close step sectioning. The determination of stage, margin status, tumor number, individual tumor volume, and total tumor volume was obtained from the pathologic evaluation. Clinical follow-up was available for 265 patients.

RESULTS

The mean patient age was 62 years, the median Gleason score was 7, the median PSA level was 5.80 ng/mL, and the median TRUS PSAD was 0.16. The percentages of concordance for PSA, TRUS PSAD, Path PSAD, and Weight PSAD were similar in predicting margin status and extracapsular extension. Using linear regression analysis, PSA was more efficacious than TRUS PSAD, Path PSAD, or Weight PSAD in predicting the total tumor volume (R2 0.11, 0.08, 0.04, and 0.06, respectively). A significant positive correlation was found among TRUS PSAD, Path PSAD, and Weight PSAD. PSA was significantly better in predicting biochemical recurrence than TRUS, Path, or Weight PSAD (concordance 75.5%, 66.6%, 66.5%, and 70.4%, respectively).

CONCLUSIONS

PSA and TRUS PSAD are significant and equivalent predictors of margin status and extracapsular extension. A marked difference may exist between PSA and TRUS PSAD in predicting the total tumor volume and biochemical recurrence.

Adenocarcinoma of the prostate: epidemiological trends, screening, diagnosis, and surgical management of localized disease

Prostate cancer is a leading cause of mortality and morbidity worldwide. Despite years of study and effort, certain key questions remain unanswered, including how prostate cancer is best detected and diagnosed, how it is best treated, and how best to minimize the complications of treatment. The aim of this article is to briefly address these topics to shed light on the current best practices in prostate cancer screening, diagnosis, and surgical treatment of localized disease. We examine current trends in prostate cancer epidemiology and screening, including genetic and dietary risk factors and the newer prostate-specific antigen-derived screening modalities. Methods of diagnosis, including an overview of prostate biopsy technique and indications, and a brief review of relevant pathologic findings are provided. An in-depth analysis of traditional prostate cancer surgical management highlights the relevant advantages and disadvantages of radical retropubic and perineal prostatectomy. Complications of surgery, prognostic factors, and the many risk prediction models currently available are discussed. In all, this article aims to give the reader a broad overview of the basic elements of prostate cancer diagnosis and surgical treatment in the modem era.

Treating the Biochemical Recurrence of Prostate Cancer After Definitive Primary Therapy

As increasing numbers of men are living longer with prostate cancer, larger proportions will eventually present to our collective practices with increasing prostate-specific antigen (PSA) levels. Such PSA relapses, conservatively estimated to affect approximately 50,000 men each year, have become the most common form of advanced prostate cancer. Salvage radiation therapy and salvage prostatectomy have important roles in our therapeutic armamentarium and should be valid options for young, healthy men. Counseling patients regarding expectations for cancer control and treatment morbidity has become better because of reports from larger series of patients who have had salvage radiation therapy and surgery. Some patients may not be appropriate candidates for salvage local therapies. A growing body of evidence suggests early hormonal therapy improves progression-free survival (PFS) and could alter cancer-specific survival. This benefit seems to be greatest when hormonal therapy is initiated while PSA levels are low, before clinically measurable disease becomes apparent. However, there is a cost to be paid in side effects and health care dollars when androgen deprivation is administered over prolonged periods. The nonsteroidal antiandrogen agent bicalutamide could offer PFS equivalent to that seen with castration without the complications of androgen deprivation. Observational data seem to indicate that individuals at high risk could also receive benefit from therapy administered before PSA detection. The potential opportunities for novel therapeutic agents with low associated morbidity are great.

Biochemical recurrence after definitive prostate cancer therapy. Part I: Defining and localizing biochemical recurrence of prostate cancer*

PURPOSE OF REVIEW

The introduction of prostate-specific antigen into clinical practice heralded a dramatic shift in the epidemiology of prostate cancer. The diagnosis and treatment of lower stage disease in younger men with fewer competing co-morbidities has resulted in a longer period of post-treatment cancer surveillance and the potential for disease recurrence. Life-long periodic prostate-specific antigen testing for biochemical recurrence is standard of care; however, there is no single definition of biochemical recurrence that reliably predicts clinical recurrence. This review explores the complexities of biochemical recurrence, a thorough understanding of which is crucial to making appropriate treatment decisions after primary treatment. It also evaluates the array of diagnostic tests frequently employed when biochemical recurrence has occurred.

RECENT FINDINGS

There is a disconnection between biochemical recurrence and progression to clinical disease. The definition of biochemical recurrence varies both by the prostate-specific antigen cut-point used and by the primary therapy employed. Furthermore, biochemical recurrence by itself appears not to be as reliable a predictor of eventual clinical recurrence as prostate-specific antigen doubling time. Current imaging modalities are rarely useful in localizing disease when biochemical recurrence is first detected.

SUMMARY

The correct interpretation of biochemical recurrence is crucial to treatment decision-making. New data show that prostate-specific antigen doubling time during prostate-specific antigen recurrence may be a valid surrogate for death from the disease. The potential therefore exists for prostate-specific antigen doubling time to be accepted as a trial endpoint, which might accelerate drug approval by the United States Food and Drug Administration.

What is the best postoperative treatment for patients with pT3bN0M0 adenocarcinoma of the prostate?

The purpose of this paper to identify the optimal therapy after radical prostatectomy (RP) for patients with adenocarcinoma of the prostate invading the seminal vesicles (pT3bN0M0 or SVI). A PubMed search using the keywords 'prostate', 'seminal vesicle', 'prostatectomy', 'radiotherapy', 'androgen blockade' was performed to identify literature regarding rates of disease failure in patients with SVI who are observed or treated with androgen blockade (AB), radiotherapy (RT) or RT + AB after RP. The outcome of 68 patients treated at Duke University with post-operative AB, RT or RT + AB for pT3bN0M0 is also presented. More than 70% of patients with SVI develop disease recurrence after surgery. For many, recurrence occurs within 2 y after RP. These patients have poor control rates with postoperative RT alone. While experience with AB and RT+AB is limited, control rates are generally superior to RT alone. At Duke University, after a median follow-up of nearly 4 y, patients treated with RT + AB or AB alone for pT3bN0M0 achieved better 5-y progression-free survival (PFS) compared with those who received RT alone (78 and 68 vs 30%, P = 0.03 and 0.046, respectively). There was no PFS difference between those who received AB alone or RT + AB (68 vs 78%, P=0.5). Seminal vesicle invasion confers a poor prognosis after RP. SVI is a consistent predictor of poor outcome after RT. The limited data available examining AB and RT + AB in pT3bN0M0 disease, including data from Duke University, are encouraging. Nonetheless, postoperative AB, RT and RT + AB for pT3bN0M0 disease require prospective evaluation, as RP alone is rarely curative.

Contemporary update of cancer control after radical prostatectomy in the UK

Despite a significant increase of the number of radical prostatectomies (RPs) to treat organ-confined prostate cancer, there is very limited documentation of its oncological outcome in the UK. Pathological stage distribution and changes of outcome have not been audited on a consistent basis. We present the results of a multicentre review of postoperative predictive variables and prostatic-specific antigen (PSA) recurrence after RP for clinically organ-confined disease. In all, 854 patient's notes were audited for staging parameters and follow-up data obtained. Patients with neoadjuvant and adjuvant treatment as well as patients with incomplete data and follow-up were excluded. Median follow-up was 52 months for the remaining 705 patients. The median PSA was 10 ng ml⁻¹. A large migration towards lower PSA and stage was seen. This translated into improved PSA survival rates. Overall Kaplan–Meier PSA recurrence-free survival probability at 1, 3, 5 and 8 years was 0.83, 0.69, 0.60 and 0.48, respectively. The 5-year PSA recurrence-free survival probability for PSA ranges <4, 4.1–10, 10.1–20 and >20 ng ml⁻¹ was 0.82, 0.73, 0.59 and 0.20, respectively (log rank, P<0.0001). PSA recurrence-free survival probabilities for pathological Gleason grade 2–4, 5 and 6, 7 and 8–10 at 5 years were 0.84, 0.66, 0.55 and 0.21, respectively (log rank, P<0.0001). Similarly, 5-year PSA recurrence-free survival probabilities for pathological stages T2a, T2b, T3a, T3b and T4 were 0.82, 0.78, 0.48, 0.23 and 0.12, respectively (log rank, P=0.0012). Oncological outcome after RP has improved over time in the UK. PSA recurrence-free survival estimates are less optimistic compared to quoted survival figures in the literature. Survival figures based on pathological stage and Gleason grade may serve to counsel patients postoperatively and to stratify patients better for adjuvant treatment.

Pfannenstiel versus Vertical Laparotomy in Patients Undergoing Radical Retropubic Prostatectomy with Spinal Anesthesia: Results of a Prospective, Randomized Trial

OBJECTIVE

To evaluate the impact of a standard vertical laparotomy versus a Pfannenstiel transverse laparotomy on intra-, peri-operative, and 6-month follow-up outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia.

METHODS

Between January 2003 and June 2003, 69 age-matched consecutive patients with clinically localized prostate cancer underwent radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia and were randomized into Group 1 (vertical laparotomy: 35 patients) and Group 2 (Pfannenstiel laparotomy: 34 patients). An extensive analysis of the critical intra-, peri-operative, and 6-month follow-up clinical parameters was performed.

RESULTS

Both the hemodynamics and the biochemical balance were not significantly different between the two groups. Overall blood loss (p = 0.78), autologous (p = 0.88) and homologous (p = 0.36) blood transfusions were similar regardless of the type of laparotomy. Surgical time was not significantly (p = 0.27) different between the two groups. Similarly, the two forms of laparotomy did not differ regarding the length of the surgical incision (p = 0.21), as measured at the end of the procedure. Post-operative oxygen saturation percentage by pulse oximetry, as well as post-op sedation score, were not significantly different (p = 0.06 and p = 0.97, respectively). Waiting time in the post-operative holding area (p = 0.15), and pain score in the post-operative holding area (p = 0.9) as well as on post-operative day 1 (p = 0.1) were not significantly different between the two groups. The rate of first flatus passage and of unassisted ambulation were similar regardless of the type of laparotomy during post-operative day day 1. The two types of incision made it possible to remove a similar (p = 0.34) number of pelvic lymph nodes and were associated to a similar rate of positive surgical margins among pT2 patients. At the 6-month follow-up the occurrence of a pelvic lymphocele and of deep venous thrombosis was similar in the two groups (p = 0.6 and p = 0.16, respectively). Complete urinary continence and spontaneous erectile function recovery was reported in a similar number of patients regardless of the type of surgical incision (p = 0.59 and p = 0.40, respectively).

CONCLUSIONS

These results suggest that a Pfannenstiel transverse suprapubic laparotomy does not result in a significantly different outcome from a standard vertical laparotomy in patients undergoing a radical retropubic prostatectomy with pelvic lymphadenectomy with L2-L3 spinal anesthesia for clinically localized prostate cancer.

Trends in Reporting Gleason Score 1991 to 2001: Changes in the Pathologist's Practice

OBJECTIVE

The prostate specific antigen (PSA) era has been associated with a grade migration towards moderately-differentiated (Gleason 5-7) prostate cancer. We investigated whether changes in interpretation of the Gleason system could be a contributing factor by reviewing the Gleason scores for prostate cancer in our region.

PATIENTS AND METHODS

Records of patients with prostate cancer assigned a Gleason score between 1991-2001 were retrospectively reviewed. We analysed trends in Gleason score, method of diagnosis and age at diagnosis. Following this, 50 cases from the dataset were randomly selected (stratified to contain half Gleason 2-4 reports) and reviewed in a blinded manner by an uropathologist and given a new Gleason score.

RESULTS

2737 patients were diagnosed and given a Gleason score; 1484 by prostate biopsy (PB) and 1172 by transurethral resection of prostate (TURP). 273 radical prostatectomy (RP) specimens were received, although the results of pre-operative biopsies were available in only 192 of these patients. Over time, there was an increase in the proportion of patients with Gleason 5-7, and a significant decrease in reporting of Gleason 2-4 cancer (r2 = 0.81, p < 0.0001). In 1991, 24% of cancers were Gleason 2-4; in 2001 this had decreased to 2.4%. TURP was associated with more Gleason 2-4 reports (23%) compared with PB (13.2%) and RP (9.2%). On blinded review, all Gleason 2-4 reports were upgraded to Gleason 5-7 cancer (p < 0.001).

CONCLUSION

Over time, the proportion of Gleason 2-4 prostate cancer reported has significantly decreased. Our study suggests that a change in practice by the pathologist is a significant factor in this grade migration.

Initial incision of lateral pelvic fascia and early ligation of vascular pedicles during radical prostatectomy: potential to reduce positive margin rates

OBJECTIVE

To report on our experience with a recently published technique to reduce positive margin (PM) rates (involving early incision of the lateral pelvic fascia, early release of the prostate and Denonvilliers' fascia off the rectum), with the additional modification of early ligation of the lateral vascular pedicles during radical retropubic prostatectomy (RP), as reducing PM rates continues to be an important oncological goal in RP.

PATIENTS AND METHODS

One hundred consecutive men (mean age 61 years, pretreatment prostate-specific antigen level 8.9 ng/mL, and estimated blood loss 502 mL) underwent RP by one surgeon. The initial dissection involves early incision of the lateral pelvic fascia and developing the plane between the prostate and underlying rectum, before any apical dissection. This incision can be made medial to the neurovascular bundles in a nerve-sparing procedure. After this plane is developed, the lateral vascular pedicles to the prostate are also divided. Once these same manoeuvres are used contralaterally, the prostate is lifted off of the rectum and held in place only by the apex and bladder neck. The apical/urethral dissection is then carried out conventionally, followed by dissection/transection of the seminal vesicles and the bladder neck.

RESULTS

The pathological stage included T2a (11%), T2b (69%), T3a (17%), T3b (3%), and N+ (2%); 20 patients had capsular penetration, at the posterolateral (in 15) and anterior aspect (in five) of the gland. The PM rate for the 100 consecutive patients was 13%, with PMs at the apex in 10, the base in two and posterolateral gland in one. No patient had a PM at the site of capsular penetration. When patients were stratified by low-moderate risk (pT2 and Gleason sum < or = 7) vs high risk (pT3 or Gleason sum > 7), the PM rates were 7.9% and 29.2%, respectively.

CONCLUSIONS

Initial dissection of the lateral pelvic fascia, including developing a "perirectal pocket", and early ligation of the lateral pedicles, resulted in a low PM rate during RP. This experience supports the previous observations that early development of the pre-rectal fat plane may allow for more precise dissection below all layers of Denonvilliers' fascia and with a wider margin of periprostatic tissue.

Salvage radiation for a rising PSA following radical prostatectomy

The purpose of this study was to evaluate the efficacy and complications of postprostatectomy therapeutic irradiation (RT) in patients with known residual disease. Between 1991 and 2003, 170 patients received therapeutic irradiation for a rising PSA following radical prostatectomy. No patients had clinical or radiological evidence of metastatic disease. The median pre-RT PSA level was 1.2 ng/mL (range, 0.2-43 ng/mL). During irradiation, the PSA level was checked weekly (median PSA determinations: 5, range, 2-7). A patient was considered to have a rise/fall of PSA if the level changed by > or = 0.2 ng/mL. There were 149 patients who received photon irradiation (median dose, 6800 cGy) and 21 patients received a combination of photon and neutron irradiation to a median photon dose equivalent of 7800 cGy. A patient was considered to have biochemical failure if his PSA level postnadir was measured at >0.2 ng/mL. Complications were graded according to the RTOG toxicity scale. The median follow-up time was 49 months (range, 1-137 months). Sixty-four patients (38%) had evidence of biochemical failure. The 7 year overall survival was 84%. At 7 years, the actuarial biochemical relapse free survival (bRFS) was 44%. Of the 59 patients with a preradiation PSA <1 ng/mL, the 5 year bRFS was 81%. This compares with 45% for both the PSA 1-4 and PSA >4 ng/mL group (P = 0.00008). The 3-year bRFS rates for patients whose PSA levels increased, decreased, and remained the same during radiation were 20%, 65%, and 76%, respectively (P = 0.0005). Overall survival at 7 years in the decreased PSA group was 88% compared to 67% for those whose PSA level increased (P = 0.43). Thirty-three percent and 19% of the patients experienced Grade 2 genitourinary (GU) and gastrointestinal (GI) complications, respectively. Six percent and 3% of the patients had Grade 3 GU and GI complications, respectively. On univariate and multivariate analysis, the factors significantly associated with a favorable outcome were a declining PSA during RT and a pre-RT PSA <1 ng/mL (P < 0.001). Radiation therapy is an effective treatment modality for select patients with a biochemical recurrence following radical prostatectomy. Patients with a low preradiation PSA level (<1.0 ng/mL) had a significantly better outcome, which supports the early use of therapeutic radiation. The observation that patients with a rising PSA level during treatment do poorly supports the routine practice of monitoring these levels during radiotherapy.

Case Selection for Radical Prostatectomy in the UK

INTRODUCTION

Radical prostatectomy is an increasingly popular treatment option for clinically localised prostate cancer, yet PSA outcome figures are rare in the UK. This makes it difficult to establish appropriate criteria for case selection. We conducted an audit of PSA recurrence of 5 large centres in the south of England and investigated the use of pre-operative PSA to improve case selection and outcome.

METHOD

854 patients notes were audited for pre-operative staging parameters and follow-up data obtained. Patients with neoadjuvant and adjuvant treatment as well as patients with incomplete data and follow-up were excluded.

RESULT

Median follow-up was 52 months for the remaining 663 patients. Median PSA was 10 ng/ml. A large improvement of PSA recurrence free survival rates was observed from 1988 to 1998 as a result of change in case selection and stage migration. Overall Kaplan-Meier PSA recurrence free survival probability at 1, 3, 5 and 8 years was 0.83, 0.69, 0.60 and 0.48, respectively. Five-year PSA recurrence free survival probability for PSA ranges <4 ng/ml, 4.1-10 ng/ml, 10.1-20 ng/ml and >20 ng/ml was 0.82, 0.73, 0.59 and 0.20, respectively (Wilcoxon, p < 0.0001). A simulation of biochemical recurrence free survival for patient cohorts with stepwise reduced inclusion PSAs suggests an improved outcome for patients with a pre-operative inclusion PSA of <12 ng/ml. Further reduction of the inclusion PSA does not improve outcome.

CONCLUSION

Intermediate PSA recurrence free survival has improved over time in England. PSA recurrence free survival estimates are less optimistic compared to frequently quoted American figures. A reduced pre-operative PSA cut-off for case selection may be used to improve outcome.

Combination hormonal therapy: a reassessment within advanced prostate cancer

Combination hormonal therapy, comprising a luteinising hormone-releasing hormone analogue (LHRHa) with an antiandrogen, is widely used in the treatment of advanced prostate cancer. There is ongoing debate regarding the use of combination hormonal therapy as opposed to LHRHa monotherapy. The pivotal consideration is whether there are adequate benefits with combination hormonal therapy in terms of increased survival and decreased disease progression to outweigh the increased risk of adverse events and additional cost. The most recent meta-analysis by the Prostate Cancer Trialists' Collaborative Group indicates a small but statistically significant survival benefit with combination hormonal therapy using nonsteroidal antiandrogens. It is, however, noteworthy that combined conclusions derived from such meta-analyses may not apply across each of the individual antiandrogens. Individual studies have reported differences between antiandrogens in terms of both tolerability and efficacy-for example, bicalutamide has been shown to be better tolerated than flutamide, and may be associated with improved survival. In addition, it is essential that treatment decisions are taken in consultation with the patient. Owing to an increasing proportion of cases presenting with early-stage disease, combination hormonal therapy is increasingly used in the neoadjuvant or adjuvant setting with radiotherapy and, in cases of prostate-specific antigen recurrence after prior localised therapy. Further data are awaited to optimise the use of combination hormonal therapy in these new settings.

Learning curve and stage migration of a radical retropubic prostatectomy series over a 10-y period

OBJECTIVE

To show the impact of learning curve and patient selection on complication rate and biochemical recurrence-free survival of a UK radical prostatectomy series for localised prostate cancer and to model the influence of common preoperative variables on biochemical recurrence after controlling for learning curve.

PATIENTS AND METHODS

From 1989 to 1999, 280 of 350 patients who underwent anatomical radical retropubic prostatectomy (RRP) at our institution had complete records and follow-up of at least 1 y. After exclusions of preoperative staging, factors reflecting the learning curve, early complications and prostate-specific antigen (PSA) outcome were recorded on 217 patients. Procedures before 1995 were compared with procedures after 1995.

RESULTS

Comparison of the two groups showed a significant decrease in operating time (mean 152 vs 130 min), blood loss (mean 1500 vs 1000 ml), transfusion rate (83 vs 42%) and hospital stay (mean 7 vs 6 days). Median preoperative PSA changed significantly from 13.2 to 11.5 ng/ml. Only 17% were diagnosed by rectal examination compared to 27% in the early years. The number of clinical T1 tumours increased from 33 to 47%. This did lead to an increase of organ-confined tumours on pathological staging by 25%. Biochemical recurrence-free survival improved significantly after 1995. After controlling for the learning curve PSA and clinical stage were significant predictors of PSA recurrence.

CONCLUSION

Time trends of case selection, stage migration and a steep learning curve are shown over a 10-y period. Factors associated with the learning curve as well as case selection have a significant impact on outcome. There may be other as yet not specified factors over time, which have a significant impact on PSA recurrence-free survival. Patients with a PSA of 20 ng/ml and above have a poor outcome and do not appear to be suitable candidates for RRP.

Cost comparison of radical retropubic and radical perineal prostatectomy: single institution experience

OBJECTIVES

To perform a detailed comparison of the in-house hospital costs of patients undergoing radical perineal prostatectomy (RPP) and radical retropubic prostatectomy (RRP) performed with or without bilateral staging lymph node dissection (BPLND) for localized prostate cancer.

METHODS

A retrospective cost review was done of a cohort of 402 consecutive radical prostatectomies performed at our institution during a 21-month period. The procedure was performed as RPP in 279 (69.4%) and RRP in 123 (30.6%) patients, of whom 10.4% and 61.8%, respectively, underwent BPLND under the same anesthesia. The hospital costs were evaluated for each patient using the categories of surgical, nursing, laboratory/transfusion, and pharmacy. Surgical costs were further subdivided into operating room, anesthesia, and recovery room costs. Univariate and multivariate statistical analyses were applied to identify predictors of procedure-related costs.

RESULTS

The median hospital costs of patients undergoing RPP (7195 dollars, range 5052 dollars to 36,237 dollars) were substantially lower than those of patients undergoing RRP (9757 dollars, range 6935 dollars to 27,771 dollars; P = 0.001). The median costs for patients undergoing radical prostatectomy without BPLND were significantly lower in the RPP (7100 dollars, range 5052 dollars to 28,604 dollars) versus RRP (9169 dollars, range 6935 dollars to 16,705 dollars) patients (P = 0.001). The costs for RPP with BPLND (10,048 dollars, range 7529 dollars to 36,237 dollars) versus RRP with BPLND (9973 dollars, range 7658 dollars to 27,771 dollars) were not significantly different (P = 0.900). Patient age and nerve-preservation status did not significantly influence the procedure-related hospital costs.

CONCLUSIONS

RPP may result in lower in-house costs per patient than RRP in those patients who do not require BPLND. Total hospital costs depend largely on the factors of operating room time, length of stay, and laboratory and transfusion requirements, which may vary among institutions.

Time trends in case selection, stage and prostate-specific antigen recurrence after radical prostatectomy: a multicentre audit

OBJECTIVES

To report an audit of preoperative staging variables, case selection, stage migration and prostate-specific antigen (PSA) recurrence at five large centres in the south of England. To establish PSA outcome values after radical prostatectomy for clinically localized prostate cancer in the UK, and enable appropriate patient counselling.

PATIENTS AND METHODS

The notes of 854 patients were audited for preoperative staging variables and follow-up data obtained. Patients with neoadjuvant and adjuvant treatment, and with incomplete data and follow-up, were excluded.

RESULTS

The median follow-up was 52 months for the remaining 663 patients; the median PSA level was 10 ng/mL. There was a large migration towards lower PSA and stage; this translated into improved PSA survival rates. The overall Kaplan-Meier PSA recurrence-free survival probability at 1, 3, 5 and 8 years was 0.83, 0.69, 0.60 and 0.48, respectively. The 5-year PSA recurrence-free survival probabilities for PSA levels of < 4, 4.1-10, 10.1-20 and > 20 ng/mL were 0.82, 0.73, 0.59 and 0.20, respectively (Wilcoxon, P < 0.001). The PSA recurrence-free survival probabilities for biopsy Gleason grade 2-4, 5 and 6, 7 and 8-10 at 5 years were 0.70, 0.61, 0.55 and 0.21, respectively (Wilcoxon, P < 0.001). Similarly, the 5-year PSA recurrence-free survival probabilities for clinical stages T1a and 1b, T1c, T2a and T2b were 0.79, 0.62, 0.57 and 0.44, respectively (Wilcoxon, P = 0.0012).

CONCLUSION

With better case selection the intermediate oncological outcome has improved over time in the UK. PSA recurrence-free survival estimates are less optimistic than the frequently quoted American values. The present values may be used to help in counselling British patients before radical prostatectomy.

Early Versus Delayed Hormonal Therapy for Prostate Specific Antigen Only Recurrence of Prostate Cancer After Radical Prostatectomy

PURPOSE

Hormonal therapy (HT) is the current mainstay of systemic treatment for prostate specific antigen (PSA) only recurrence (PSAR), however, there is virtually no published literature comparing HT to observation in the clinical setting. The goal of this study was to examine the Department of Defense Center for Prostate Disease Research observational database to compare clinical outcomes in men who experienced PSAR after radical prostatectomy by early versus delayed use of HT and by a risk stratified approach.

MATERIALS AND METHODS

Of 5382 men in the database who underwent primary radical prostatectomy (RP), 4967 patients were treated in the PSA-era between 1988 and December 2002. Of those patients 1352 men who had PSAR (PSA after surgery greater than 0.2 ng/ml) and had postoperative followup greater than 6 months were used as the study cohort. These patients were further divided into an early HT group in which patients (355) received HT after PSA only recurrence but before clinical metastasis and a late HT group for patients (997) who received no HT before clinical metastasis or by current followup. The primary end point was the development of clinical metastases. Of the 1352 patients with PSAR clinical metastases developed in 103 (7.6%). Patients were also stratified by surgical Gleason sum, PSA doubling time and timing of recurrence. Univariate and multivariate Cox proportional hazard models were used to evaluate the effect of early and late HT on clinical outcome.

RESULTS

Early HT was associated with delayed clinical metastasis in patients with a pathological Gleason sum greater than 7 or PSA doubling time of 12 months or less (Hazards ratio = 2.12, p = 0.01). However, in the overall cohort early HT did not impact clinical metastases. Race, age at RP and PSA at diagnosis had no effect on metastasis-free survival (p >0.05).

CONCLUSIONS

The retrospective observational multicenter database analysis demonstrated that early HT administered for PSAR after prior RP was an independent predictor of delayed clinical metastases only for high-risk cases at the current followup. Further study with longer followup and randomized trials are needed to address this important issue.

Epidemiology of prostate cancer

Prostate cancer incidence and mortality rates vary worldwide. In the United States, prostate cancer is the most common malignancy affecting men and is the second-leading cause of cancer death. Risk of developing prostate cancer is associated with advancing age, African American ethnicity, and a positive family history, and may be influenced by diet and other factors. The incidence of prostate cancer increased sharply after the introduction of widespread screening for prostate-specific antigen (PSA), although rates have now returned to levels seen before that time. PSA screening has been associated with a shift toward diagnosis of earlier-stage disease, but this has not been accompanied by a shift toward a lower histologic grade. Although overall prostate cancer mortality rates decreased during the 1990s, it was largely because of reductions in deaths among men diagnosed with distant disease. In contrast, mortality rates for men diagnosed with localized or regional disease increased gradually during most of the 1990s before decreasing slightly among white men and reaching plateaus among African Americans.

Time trends in clinical risk stratification for prostate cancer: implications for outcomes (data from CaPSURE)

PURPOSE

Many instruments designed to predict prostate cancer risk use a combination of clinical T stage, biopsy Gleason score and serum prostate specific antigen (PSA). We designed a study to characterize time trends in these parameters and their impact on patient risk stratification.

MATERIALS AND METHODS

Data were abstracted from CaPSURE (Cancer of the Prostate Strategic Urological Research Endeavor), a disease registry of 8,685 men with prostate cancer. The 6,260 men diagnosed since 1989 who had complete clinical information reported were categorized into low, intermediate or high risk groups based on established parameters for T stage, Gleason score and PSA.

RESULTS

Between 1989 to 1990 and 2001 to 2002 the proportion of patients presenting with high, intermediate and low risk disease changed from 40.9%, 28.0% and 31.2% to 14.8%, 37.5% and 47.7%, respectively (p <0.0001). The incidence of T1 tumors increased from 16.7% to 48.5% and that of T3-4 tumors decreased from 11.8% to 3.5%, respectively (p <0.0001). The incidence of Gleason 2 to 6 tumors decreased from 77.1% to 66.4%, while that of Gleason 7 tumors increased from 12.9% to 24.8%, respectively (p = 0.0030). PSA levels 10 ng/ml or less increased from 43.6% to 77.7%, respectively, while PSA 10 to 20 and greater than 20 ng/ml decreased accordingly (p <0.0001). These trends were mirrored in subset analysis of black patients.

CONCLUSIONS

A significant downward risk migration has occurred over time. Gleason score is now more likely and PSA less likely than previously to drive risk assignment. This shift is most likely attributable to changes in practice patterns with respect to screening and pathological grading. These changes should be considered when applying nomograms derived from earlier datasets to contemporary cases.

Evolution of therapeutic approaches with luteinizing hormone–releasing hormone agonists in 2003

The role of hormone therapy in the current era of widespread testing for prostate-specific antigen (PSA) continues to evolve. Although still used in patients with metastatic disease, the most common uses of luteinizing hormone-releasing hormone (LHRH) agonist therapy are in the adjuvant and neoadjuvant settings with radiotherapy and sometimes with radical prostatectomy, as well as in the treatment of PSA-only recurrence. Immediate (adjuvant) hormone therapy after prostatectomy may provide a survival advantage relative to deferred treatment in high-risk patients, whereas the survival benefit of adjuvant therapy with radiation is clearer. Combined androgen blockade with an LHRH agonist and a nonsteroidal antiandrogen provides a very modest but statistically significant survival benefit relative to LHRH agonist monotherapy in patients with metastatic disease, but it has not been proved in those with less advanced disease. Intermittent hormone therapy appears to be effective in maintaining disease control for several years, but randomized studies are needed to determine if survival is at least equivalent to continuous therapy. Finally, LHRH agonist therapy is commonly used in the setting of biochemical or PSA-only recurrence. However, there are no randomized controlled trials to prove a survival benefit over observation. In summary, hormone therapy now plays a more important role at earlier stages of disease, consistent with the changing epidemiology of prostate cancer. Additional studies are needed, however, to define how to optimally use hormone therapy across various patient types.

Continued undertreatment of older men with localized prostate cancer

OBJECTIVES

To explore the association among patient factors (age, comorbidity), disease-specific factors (stage, Gleason score), and suboptimal initial treatment in a cohort of men with localized prostate cancer.

METHODS

An age-stratified, geographically representative cohort of 276 patients with localized prostate cancer diagnosed in 1995 to 1996 was identified using the Ontario Cancer Registry. Data describing age, comorbidity, Gleason score, stage, and treatment received were abstracted by chart review. A previously developed Markov state-transition model was used to estimate the optimal treatment for each patient. A logistic regression model was developed to estimate the predictors of suboptimal treatment. The treatment received was compared with the predicted optimal treatment. Suboptimal treatment occurred when the difference between the optimal treatment and treatment received was clinically important (thresholds of 0.2 to 1.0 life year or quality-adjusted life year).

RESULTS

Of 276 patients, 41 (14.9%) received suboptimal treatment. Age, Gleason score, and comorbidity were independent predictors of suboptimal treatment. Healthy men aged 70 years or older, with Gleason scores of 5 to 7 or 8 to 10 had the greatest proportion of suboptimal treatment (46.9% and 72.7%, respectively). The average quality-adjusted life expectancy lost for healthy men aged 70 to 79 years with Gleason scores of 5 to 7 and 8 to 10 was 0.62 year and 0.93 year per patient, respectively.

CONCLUSIONS

Otherwise healthy men in their 70s and 80s with localized prostate cancer are often receiving watchful waiting and potentially losing valuable years of life. Many of these patients with at least moderate-grade disease may benefit from potentially curative therapy (radical prostatectomy or radiotherapy).

Early prostate cancer: prevention, treatment modalities, and quality of life issues

Our understanding of the screening, prevention and treatment of early prostate cancer is improving. This is a result of new data from clinical trials and the incorporation of efficacy measures based on risk assessment and quality of life (QoL). This review aims to examine completed and ongoing clinical trials that address issues in early prostate cancer, including screening, prevention, treatment, and QoL. Prostate-specific antigen (PSA) testing has a crucial and evolving role in detecting primary prostate cancer, evaluating prevention interventions and assessing the effectiveness of treatment. Questions remain about the optimal PSA parameters appropriate for primary screening and for diagnosing relapse. Emerging and established data provide evidence that early intervention with hormone therapy, either as immediate or adjuvant therapy, delays progression in prostate cancer patients with intermediate or poor prognosis. The impact of therapeutic modality on QoL has become better characterized, as QoL instruments have been developed, validated and applied.

National practice patterns and time trends in androgen ablation for localized prostate cancer

BACKGROUND

Recent reports have suggested that growing numbers of patients with localized prostate cancer are receiving androgen deprivation therapy as primary or neoadjuvant treatment, yet sparse clinical evidence supports the use of such treatment except among patients with high-risk or locally advanced disease receiving external beam radiotherapy. We describe national trends in the use of androgen deprivation therapy for localized disease.

METHODS

CaPSURE is an observational database of 7195 patients with prostate cancer. This study included 3439 of these patients who were diagnosed since 1989, had clinical staging information available, and were treated with radical prostatectomy, radiation therapy, or primary androgen deprivation therapy (PADT). High-, intermediate-, and low-risk groups were defined by serum prostate-specific antigen level, Gleason score, and clinical tumor stage. Time trends in the use of PADT and neoadjuvant androgen deprivation therapy (NADT) were analyzed. All statistical tests were two-sided.

RESULTS

Rates of PADT use rose sharply between 1989 and 2001, from 4.6% (95% confidence interval [CI] = 3.4% to 5.8%) to 14.2% (95% CI = 12.2% to 16.2%), from 8.9% (95% CI = 7.3% to 10.5%) to 19.7% (95% CI = 17.5% to 21.9%), and from 32.8% (95% CI = 29.9% to 35.7%) to 48.2% (95% CI = 45.1% to 51.3%) (all P<.001) in low-, intermediate-, and high-risk groups, respectively. NADT use also increased in association with radical prostatectomy (2.9% [95% CI = 2.1% to 3.7%] to 7.8% [95% CI = 6.5% to 9.1%] of patients, P =.003) and external beam radiotherapy (9.8% [95% CI = 7.5% to 12.1%] to 74.6% [95% CI = 70.8% to 78.4%], P<.001) across all risk levels combined. Rates of NADT use among patients treated with brachytherapy also increased but not statistically significantly (7.4% [95% CI = 3.5% to 11.3%] to 24.6% [95% CI = 18.2% to 31.0%], P =.100).

CONCLUSIONS

Rates of both PADT and NADT are increasing across risk groups and treatment types. Future clinical trials must define more clearly the appropriate role of hormonal therapy in localized prostate cancer, and their results should shape updated practice guidelines.

Variables in predicting survival based on treating "PSA-only" relapse

Prostate cancer recurrence (after prior local treatment) that is detectable only by a rise in serum prostate specific antigen (PSA) level is a very common problem facing clinicians. Given that the majority of contemporary era men with PSA-only or biochemical recurrence are relatively young and otherwise healthy, treatment requires approaches that both improve clinical outcomes and preserve quality of life. Treatment is in one of two broad categories, additional local therapies, termed "salvage" local therapy and systemic therapies. For radical prostatectomy patients, salvage external beam radiotherapy to the prostate bed is commonly employed, being reserved for early biochemical recurrence in men with low risk at distant metastases. For primary radiation patients, salvage radical prostatectomy or cryotherapy can similarly be used for those men felt not to harbor distant metastases. Systemic therapy generally involves hormonal therapy. Traditional hormonal therapy (orchiectomy, luteinizing hormone-releasing hormone agonists, or maximum androgen blockade) is the current mainstay of systemic treatment for biochemical recurrence, although nontraditional approaches, such as antiandrogen monotherapy, are increasingly being used. Variables in predicting survival based on treating PSA relapse is problematic. The condition of biochemical failure has only been recognized in the last decade and few "PSA-era" patients with biochemical recurrence have actually died of disease. Hence, the validation of prediction variables in this setting is just emerging. Early work would suggest that timing of recurrence, Gleason grade, and PSA velocity or doubling time during relapse are important prognostic factors. New data on PSA doubling time will be presented.

Ten-Year Survival After Radical Prostatectomy: Specimen Gleason Score Is the Predictor in Organ-Confined Prostate Cancer

Pathologic stage is a major prognostic factor in patients with clinically localized prostate cancer. However, disease recurrence occurs even in patients with organ-confined disease. With the advent of prostate-specific antigen (PSA) testing, the percentage of patients with pathologically organ-confined tumors has increased significantly. We studied clinical/pathologic factors that will predict disease recurrence in patients with pathologically organ-confined tumors. Patients with clinically localized newly diagnosed prostate cancer who had not received prior therapeutic intervention but who underwent radical prostatectomy as definitive treatment between 1990 and 1999, were included in this study. Clinical/pathologic parameters including age, race, clinical stage, preoperative PSA, and biopsy and specimen Gleason scores (grouped as 2-6, 7, and 8-10) were correlated with disease-free survival in patients with organ-confined disease. Metastasis-free and cancer-specific survival for the cohort was also assessed. A total of 1045 patients fulfilled our inclusion criteria. Overall, the 10-year estimates of PSA progression-free, metastasis-free, and cancer-specific survival were 75%, 91%, and 92%, respectively. Cancer was confined to the prostate in 532 of 1045 patients (51%), of whom 96% (511 of 532) remain PSA progression-free, compared to 65% (335 of 513) with extraprostatic disease (P = 0.0001). Interestingly, in patients with organ-confined disease, the specimen Gleason score was the only prognostic factor for disease recurrence after multivariable analysis. Radical prostatectomy provided excellent cancer control. For patients with pathologically organ-confined tumors, the specimen Gleason score is the only factor predictive of disease-free survival. Of note, Gleason scores of 8-10 are uncommon in these patients.

Is there age bias in the treatment of localized prostate carcinoma?

BACKGROUND

Treatment recommendations for localized prostate carcinoma are based on the patient's remaining life expectancy (RLE), which is influenced by age, comorbidity, and tumor grade. Previous studies have evaluated the influence of age and comorbidity, but to the authors' knowledge not RLE, on actual treatment decisions.

METHODS

An age-stratified random sample of 347 patients was generated from a cohort of all patients with newly diagnosed prostate carcinoma in the Ontario Cancer Registry between May 1, 1995 and April 30, 1996 (n = 5192). Chart review was performed to obtain detailed tumor, comorbidity, and treatment information. RLE was estimated from a published model derived from a cohort of 451 men with untreated prostate carcinoma who were followed for 15 years. Multivariable logistic regression was performed to evaluate predictors of treatment, such as radical prostatectomy (RP), radiotherapy (RT), or potentially curative therapy (RP or RT), in relation to patient age, comorbidity, tumor characteristics, and RLE.

RESULTS

RP was provided within 6 months of diagnosis to 58.7%, 32.1%, 2.6%, and 0% of patients of ages < 60 years, 60-69 years, 70-79 years, and 80+ years, respectively. The results for RT were 6.4%, 30.9%, 23.4%, and 3.3%, respectively. Increasing comorbidity decreased rates of RP but did not affect use of RT. After controlling for comorbidity and tumor characteristics, older men were found to be treated with RP less often than younger men with similar RLE, whereas RLE did not appear to influence receipt of RT.

CONCLUSIONS

Although different mechanisms may account for these results, an age bias may be present among urologists and radiation oncologists treating men with localized prostate carcinoma.