Lower prostate specific antigen outcome than expected following radical prostatectomy in patients with high grade prostate and a prostatic specific antigen level of 4 ng/ml. Or less

Mortality Risk for Docetaxel-Treated, High-Grade Prostate Cancer With Low PSA Levels: A Meta-Analysis

Importance

Patients with high-grade prostate cancer with low levels of prostate-specific antigen (PSA; <4 ng/mL) are at high risk of mortality, necessitating an improved treatment paradigm.

Objective

To assess for these patients whether adding docetaxel to standard of care (SOC) treatment is associated with decreased prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM).

Data Sources

PubMed search from 2000 to 2022.

Study Selection

Five prospective randomized clinical trials (RCTs) performed in the US, France, and the United Kingdom evaluating SOC treatment with radiotherapy and androgen deprivation therapy (ADT) or with radical prostatectomy vs SOC plus docetaxel.

Data Extraction and Synthesis

Individual data were included from patients with nonmetastatic prostate cancer, a PSA level of less than 4 ng/mL, and a Gleason score of 8 to 10. Patients initiated treatment between February 21, 2006, and December 31, 2015 (median follow-up, 7.1 [IQR, 5.4-9.9] years). Data were analyzed on December 16, 2022.

Main Outcomes and Measures

Hazard ratio (HR) of ACM and subdistribution HR (sHR) of PCSM adjusted for performance status (1 vs 0 or good health), Gleason score (9 or 10 vs 8), tumor category (T3-T4 vs T1-T2 or TX), and duration of ADT (2 years vs 4-6 months).

Results

From a cohort of 2184 patients, 145 patients (6.6%) in 4 RCTs were eligible (median age, 63 [IQR, 46-67] years). Thirty-one patients died, and of these deaths, 22 were due to prostate cancer. Performance status was 0 for 139 patients (95.9%) and 1 for 6 patients (4.1%). A reduced but nonsignificant risk of ACM (HR, 0.51 [95% CI, 0.24-1.09]) and PCSM (sHR, 0.42 [95% CI, 0.17-1.02]) was associated with patients randomized to SOC plus docetaxel compared with SOC. The risk reduction in ACM (HR, 0.46 [95% CI, 0.21-1.02]) was more pronounced among patients with a performance status of 0 and was significant for PCSM (sHR, 0.30 [95% CI, 0.11-0.86]).

Conclusions and Relevance

Adding docetaxel to SOC treatment for patients who are in otherwise good health with a PSA level of less than 4 ng/mL and a Gleason score of 8 to 10 was associated with a significant reduction in PCSM and therefore has the potential to improve prognosis.

Variations in genomic regions encoding long non-coding RNA genes associated with increased prostate cancer risk

From a single restriction fragment length polymorphism analysis to next generation sequencing analysis that screens the entire human genome, testing for genomic variations provides a great and robust approach to cancer testing. Non-coding RNAs have been shown to have a major impact on the development and progression of human cancers, including prostate cancer. However, the low stability of these molecules under laboratory conditions has made their clinical utility challenging, as in the case of PCA3 long non-coding RNA. Since testing for variations in genomic regions encoding non-coding RNAs offers a promising approach for cancer testing, identification and interpretation of single nucleotide polymorphisms associated with prostate cancer susceptibility is of great interest. Accordingly, here, for the first time, we review and discuss current available knowledge about genomic variation of long non-coding RNA molecules in prostate cancer.

Survival outcomes of low prostate-specific antigen levels and T stages in patients with high-grade prostate cancer: a population-matched study

Objective: To evaluate the prostate cancer-specific survival (PCSS) of low T stages or low prostate-specific antigens (PSA) levels in men with high-grade prostate cancer.

Materials and Methods: Patients with non-metastatic prostate cancer (T1-4N0M0) and Gleason score 8-10 in the Surveillance, Epidemiology, and End Results database from 2004-2010 were identified. These men were stratified by T stages (T1, T2, T3a, T3b-4) and PSA levels (<4.0 ng/ml, 4.0-10.0 ng/ml, 10.1-20.0 ng/ml, >20.0 ng/ml). Propensity-score matching (PSM) was conducted to balance the covariates. Kaplan-Meier analysis and multivariable Cox regressions were performed to analyze the PCSS in different T stage or PSA levels groups.

Results: A total of 33231 patients aging 69(62~76) years were identified. The overall cohort results showed that the PCSS of T1 group was significantly worse than that of T2 and T3a groups [T2 HR: 0.62(0.57~0.67); T3 HR: 0.70(0.63~0.77)]. There were no significant difference between T2 and T3a groups [T2 HR: 0.98 (0.91~1.05)]. The PSA <4.0 ng/ml group had significantly worse PCSS than PSA 4.0-10.0 ng/ml [PSA 4.0-10.0 ng/ml HR: 0.77(0.68~0.88)]. PSM methods were implemented in the comparison of T1 vs T2, T1 vs T3a, T2 vs T3a. and PSA< 4.0 ng/ml vs PSA 4.0-10.0 ng/ml, The results in these matched cohorts showed that T1 group was associated with significantly worse PCSS than T2 group [T1 HR: 1.31(1.20~1.44)] and T3a group [T1 HR: 1.33(1.16~1.52)]. There were no significant differences between T2 and T3a groups [T3a HR: 1.14(0.99~1.32)]. The PCSS of patients with PSA< 4.0 ng/ml was significantly worse that these with PSA 4.0-10.0 ng/ml in the matched cohort [PSA< 4.0 ng/ml HR: 1.3(1.08~1.56)].

Conclusions: For patients with high-grade PCa, the PCSS of patients seems to be worse in the T1 stage than those in T2 and T3a stages. Patients with PSA <4.0 ng/ml appears to have poorer prognosis than those with PSA 4.0-10.0 ng/ml.

Association between preoperative prostate-specific antigen levels and mortality in high- and intermediate-grade prostate cancer patients who received radical prostatectomy: Findings from the SEER database

Background

The degree of expression of prostate-specific antigen (PSA) has been applied for the purpose of screening and monitoring the progression of prostate cancer. The goal of this study was to evaluate the association between preoperative PSA levels and mortality outcomes in men with high- and intermediate-grade prostate cancer who received radical prostatectomy.

Methods

The 2004–2014 files of the Surveillance, Epidemiology, and End Result database were analyzed. A total of 97,357 patients with non-metastatic high- and intermediate-grade adenocarcinoma of the prostate who received radical prostatectomy were identified. Using Kaplan–Meier estimates and multivariable Cox proportional hazard models, the relationship between preoperative PSA values and cancer-specific mortality outcomes in men with high- and intermediate-grade prostate cancer who received radical prostatectomy was tested.

Results

Of 97,357 patients with high- and intermediate-grade prostate cancer who received radical prostatectomy from 2001 to 2014, there were 983 cancer-specific deaths, and the average follow-up time for the cohort was 85.0 (34.6) months. Preoperative PSA values > 10 ng/ml were associated with greater risk of cancer-specific mortality (hazard ratio 2.3, P < 0.0001) when compared to the referent/normal values for preoperative PSA (<4 ng/ml). Individuals with preoperative PSA values 4–10 ng/ml had lower risk of prostate cancer-specific mortality (hazard ratio 0.80, P = 0.03) when compared to individuals with normal preoperative PSA values.

Conclusions

Individuals with preoperative PSA values 4–10 ng/ml had 20% lower risk of prostate cancer-specific mortality when compared to individuals with preoperative PSA values of <4 ng/dl. The findings from this study suggest that low or normal preoperative PSA values may not always mean that prostate cancer is indolent, and more work needs to be done to better classify risk in men with prostate cancer.

Reduced cancer-specific survival of low prostate-specific antigen in high-grade prostate cancer: A population-based retrospective cohort study

OBJECTIVE

The aim of this study was to evaluate the survival outcomes of different prostate-specific antigens (PSA) levels in men with high-grade prostate cancer.

MATERIALS AND METHODS

From 2004 to 2015 in the Surveillance, Epidemiology, and End Results database, men diagnosed with clinically localized prostate cancer and a Gleason score (GS) 8-10 were identified. Patients were divided into the PSA levels <4.0 ng/ml, 4.0-10.0 ng/ml, 10.1-20.0 ng/ml, and >20.0 ng/ml groups. Multivariable Cox regressions and Kaplan-Meier analysis were adopted to analyze the prostate cancer-specific survival (PCSS).

RESULTS

59,336 men with a median age of 70 (63-76) years with a GS 8-10 were included. The PCSS of patients with a PSA <4.0 ng/ml was significantly worse than that of patients with a PSA 4.0-10.0 ng/ml [hazard ratio (HR): 1.43 (1.28-1.58)], but was better than that of patients with a PSA 10.1-20.0 ng/ml [HR: 1.18 (1.06-1.31)]. After stratifying patients by GS, the differences between patients with a PSA <4.0 ng/ml and a PSA 4.0-10.0 ng/ml were only significant in those with a GS 9 and 10 [GS 9 HR: 1.49 (1.28-1.72); GS 10 HR: 1.42 (1.12-1.8)], but not in those with a GS 8 [HR: 1.04 (0.95-1.14)]. Moreover, the PCSS of patients with a PSA <4.0 ng/ml and a PSA 10.0-20.0 ng/ml were similar in patients with GS 9 and 10 diseases [GS 9: HR: 1.06 (0.91-1.23); GS 10: HR: 1.13 (0.89-1.44)].

CONCLUSIONS

Patients with a PSA <4.0 ng/ml had poorer PCSS than patients with a PSA 4.0-10.0 ng/ml. Similar PCSS was found in patients whose PSA levels were 10.1-20.0 ng/ml in patients with GS 9-10 prostate cancer.

Clinical and Genomic Characterization of Low-Prostate-specific Antigen, High-grade Prostate Cancer

BACKGROUND

The consequences of low prostate-specific antigen (PSA) in high-grade (Gleason 8-10) prostate cancer are unknown.

OBJECTIVE

To evaluate the clinical implications and genomic features of low-PSA, high-grade disease.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective study of clinical data for 494 793 patients from the National Cancer Data Base and 136 113 patients from the Surveillance, Epidemiology, and End Results program with cT1-4N0M0 prostate cancer (median follow-up 48.9 and 25.0 mo, respectively), and genomic data for 4960 patients from the Decipher Genomic Resource Information Database. Data were collected for 2004-2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable Fine-Gray and Cox regressions were used to analyze prostate cancer-specific mortality (PCSM) and all-cause mortality, respectively.

RESULTS AND LIMITATIONS

For Gleason 8-10 disease, using PSA 4.1-10.0ng/ml (n=38 719) as referent, the distribution of PCSM by PSA was U-shaped, with an adjusted hazard ratio (AHR) of 2.70 for PSA ≤2.5ng/ml (n=3862, p<0.001) versus 1.97, 1.36, and 2.56 for PSA of 2.6-4.0 (n=4199), 10.1-20.0 (n=17 372), and >20.0ng/ml (n=16 114), respectively. By contrast, the distribution of PCSM by PSA was linear for Gleason ≤7 (using PSA 4.1-10.0ng/ml as the referent, n=359 898), with an AHR of 0.41 (p=0.13) for PSA ≤2.5ng/ml (n=37 812) versus 1.38, 2.28, and 4.61 for PSA of 2.6-4.0 (n=54 152), 10.1-20.0 (n=63 319), and >20.0ng/ml (n=35 459), respectively (p_interaction<0.001). Gleason 8-10, PSA ≤2.5ng/ml disease had a significantly higher PCSM than standard high-risk/very high-risk disease with PSA >2.5ng/ml (AHR 2.15, p=0.002; 47-mo PCSM 14% vs 4.9%). Among Gleason 8-10 patients treated with radiotherapy, androgen deprivation therapy was associated with a survival benefit for PSA >2.5ng/ml (AHR 0.87; p<0.001) but not ≤2.5ng/ml (AHR 1.36; p=0.084; p_interaction=0.021). For Gleason 8-10 tumors, PSA ≤2.5ng/ml was associated with higher expression of neuroendocrine/small-cell markers compared to >2.5ng/ml (p=0.046), with no such relationship for Gleason ≤7 disease.

CONCLUSIONS

Low-PSA, high-grade prostate cancer has very high risk for PCSM, potentially responds poorly to androgen deprivation therapy, and is associated with neuroendocrine genomic features.

PATIENT SUMMARY

In this study, we found that low-prostate-specific antigen, high-grade prostate cancer has a very high risk for prostate cancer death, may not respond well to androgen deprivation therapy, and is associated with neuroendocrine genomic features. These findings suggest that current nomograms and treatment paradigms may need modification.

Reduction in expression of the benign AR transcriptome is a hallmark of localised prostate cancer progression

Background

Despite the importance of androgen receptor (AR) signalling to prostate cancer development, little is known about how this signalling pathway changes with increasing grade and stage of the disease.

Objective

To explore changes in the normal AR transcriptome in localised prostate cancer, and its relation to adverse pathological features and disease recurrence.

Design

Publically accessible human prostate cancer expression arrays as well as RNA sequencing data from the prostate TCGA. Tumour associated PSA and PSAD were calculated for a large cohort of men (n=1108) undergoing prostatectomy.

Outcome Measurements and Statistical Analysis

We performed a meta-analysis of the expression of an androgen-regulated gene set across datasets using Oncomine. Differential expression of selected genes in the prostate TCGA database was probed using the edgeR Bioconductor package. Changes in tumour PSA density with stage and grade were assessed by Student's t-test, and its association with biochemical recurrence explored by Kaplan-Meier curves and Cox regression.

Results

Meta-analysis revealed a systematic decline in the expression of a previously identified benign prostate androgen-regulated gene set with increasing tumour grade, reaching significance in nine of 25 genes tested despite increasing AR expression. These results were confirmed in a large independent dataset from the TCGA. At the protein level, when serum PSA was corrected for tumour volume, significantly lower levels were observed with increasing tumour grade and stage, and predicted disease recurrence.

Conclusions

Lower PSA secretion-per-tumour-volume is associated with increasing grade and stage of prostate cancer, has prognostic relevance, and reflects a systematic perturbation of androgen signalling.

Prostate cancer-specific death in brachytherapy treated high-risk patients stratified by pre-treatment PSA

Purpose

To evaluate prostate-cancer specific mortality (PCSM) in a cohort of high-risk patients treated with a permanent prostate brachytherapy approach, stratified by pre-treatment PSA.

Material and methods

448 high-risk patients (NCCN criteria) underwent permanent prostate brachytherapy. High risk patients were stratified by pre-treatment PSA (≤ 10.0, 10.1-20, and > 20 ng/ml). Biochemical failure (BF), prostate cancer-specific mortality (PCSM), distant failure (DM), and overall mortality (OM) were assessed as a function of prognostic group. Multiple clinical, treatment, and dosimetric parameters were evaluated for impact on outcome.

Results

The 10-year OM, BF, and PCSM for the entire cohort were 28.5%, 13.3%, and 4.9%, respectively. At 10 years, PCSM was 2.5%, 10.7%, and 4.5% in the PSA ≤ 10, 10.1-20, and > 20 ng/ml groups, respectively. No statistically significant differences in BF or overall survival (OS) were noted when stratified by pre-treatment PSA. DF was the most common in the 10.1-20 ng/ml cohort (8.6% at 10 years). In multivariate analysis, PCSM was most closely related to percent positive biopsies (p = 0.001) and tobacco (p = 0.042).

Conclusions

High-risk prostate cancer treated with permanent prostate brachytherapy and supplemental external beam radiotherapy resulted in excellent long-term biochemical control and PCSM. Overall, PCSM was low in all cohorts but highest in the intermediate PSA group (10.1-20 ng/ml).

Association of very low prostate-specific antigen levels with increased cancer-specific death in men with high-grade prostate cancer

BACKGROUND

The objective of this study was to determine whether a very low presenting prostate-specific antigen (PSA) level was associated with greater prostate cancer-specific mortality (PCSM) among men with a Gleason score (GS) of 8 to 10.

METHODS

The Surveillance, Epidemiology, and End Results program was used to identify 328,904 men diagnosed with clinicalT1 (cT1)-4N0M0 prostate cancer between 2004 and 2010. A multivariate Fine-Gray competing risks regression analysis was used to determine PCSM as a function of the PSA level (≤ 2.5, 2.6-4, 4.1-10, 10.1-20, 20.1-40, or > 40 ng/mL) and GS (8-10 vs ≤ 7).

RESULTS

The median follow-up was 38 months. Among men with GS 8-10 disease, with a PSA level of 4.1 to 10 ng/mL as the referent, the adjusted hazard ratio for PCSM for men was 2.15 with a PSA level ≤ 2.5 ng/mL (95% confidence interval [CI], 1.65-2.79; P < .001), 1.60 with a PSA level of 2.6 to 4 ng/mL (95% CI, 1.22-2.10; P = .001), 1.60 with a PSA level of 10.1 to 20 ng/mL (95% CI, 1.41-1.82; P < .001), 2.08 with a PSA level of 20.1 to 40 ng/mL (95% CI, 1.81-2.38; P < .001), and 3.23 with a PSA level > 40 ng/mL (95% CI, 2.85-3.65; P < .001). This suggested a U-shaped distribution. There was a significant interaction between the PSA level and GS (P(interaction)  < .001) such that only a PSA level ≤ 2.5 ng/mL significantly predicted poorer PCSM among patients with GS 8-10 disease.

CONCLUSIONS

Among patients with high-grade disease, patients with PSA levels ≤ 2.5 ng/mL or PSA levels of 2.6 to 4 ng/mL appear to have a higher risk for cancer-specific death in comparison with patients with PSA levels of 10.1 to 20 ng/mL, and this supports the notion that low PSA levels in GS 8-10 disease may be a sign of aggressive and very poorly differentiated or anaplastic low PSA-producing tumors. Patients with low-PSA, GS 8-10 disease should be considered for clinical trials studying the use of chemotherapy and other novel agents for very high-risk prostate cancers.

The relationship between prostate-specific antigen and TNM classification or Gleason score in prostate cancer patients with low prostate-specific antigen levels

BACKGROUND

Prostate-specific antigen (PSA) is a useful biomarker for risk classification in patients with prostate cancer. However, it is unclear whether a correlation exists between low PSA levels (<10 ng/ml) at diagnosis and prognosis.

METHODS

Of the 642 Japanese patients who underwent prostate biopsy and were diagnosed with prostate cancer at Kanazawa University Hospital from 2000 to 2010, 406 patients with a PSA level <20 ng/ml were retrospectively reviewed.

RESULTS

PSA levels in 275 (68%) patients were <10 ng/ml. Although the percentage of Gleason score 8-10 in patients with a PSA level of <3.5 ng/ml was higher than that in patients with a PSA level between 3.5 and 10 ng/ml, it was not statistically significant. On the other hand, the percentage of higher stage (T3 and T4) patients with a PSA level <3.5 ng/ml was significantly greater than that in patients with a PSA level between 3.5 and 10 ng/ml (P < 0.0001). The percentage of metastases (N1 and M1) in patients with a PSA level <3.5 ng/ml was also significantly higher than that in patients with a PSA level between 3.5 and 10 ng/ml (P = 0.0112).

CONCLUSIONS

Patients with prostate cancer with a PSA level <3.5 ng/ml at diagnosis had a more advanced stage of cancer compared with those with a PSA level between 3.5 and 10 ng/ml. Therefore, risk classification using PSA levels at diagnosis may need to take into consideration this specific PSA range in order to better predict survival.

The impact of PSA and digital rectal examination on the risk of prostate cancer specific mortality in men with a PSA level <2.5 ng/ml

INTRODUCTION

It is unknown whether a normal range, diagnostic serum prostate specific antigen (PSA) level's influence on prostate cancer specific mortality (PCSM) is dependent upon digital rectal examination (DRE) findings.

METHODS

Between 2004 and 2007, 9081 men diagnosed with non-palpable (T1c, N=1710) or palpable (T2-T4, N=7371) and non-metastatic prostate cancer (PC) were identified from surveillance, epidemiology, and end results data, selected based on pre-treatment PSA<2.5 ng/ml. A multivariable competing risks regression model evaluated whether DRE findings interacted with PSA level in predicting risk of PCSM.

RESULTS

After median follow-up of 2.83 years, 118 of 548 deaths (21.5%) were due to PC. Increasing diagnostic PSA was associated with increased risk of PCSM (AHR=3.52; 95% CI: 1.25-9.89; P=.017) in men with T1c, Gleason score 7-10 PC, but decreased PCSM risk (AHR=0.66; 95% CI: 0.52-0.83; P<.001) for men with T2-T4 PC and any Gleason score.

DISCUSSION

For men with diagnostic PSA level <2.5 ng/ml and palpable PC, risk of early PCSM increases by 34% for a 1 point decrease in PSA from 2. This suggests the existence of clinically detectable, low PSA secreting disease with an elevated risk of early PCSM, highlighting the importance of the DRE in men with PC and normal range, diagnostic PSA.

Body mass index and incidence of localized and advanced prostate cancer--a dose-response meta-analysis of prospective studies

BACKGROUND

The relationship between obesity and risk of prostate cancer (PCa) is unclear; however, etiologic heterogeneity by subtype of PCa (localized, advanced) related to obesity was suggested. Therefore, we conducted a dose-response meta-analysis of prospective studies to assess the association between body mass index (BMI) and risk of localized and advanced PCa.

MATERIALS AND METHODS

Relevant prospective studies were identified by a search of Medline and Embase databases to 03 October 2011. Twelve studies on localized PCa (1,033,009 men, 19,130 cases) and 13 on advanced PCa (1,080,790 men, 7067 cases) were identified. We carried out a dose-response meta-analysis using random-effects model.

RESULTS

For localized PCa, we observed an inverse linear relationship with BMI [Ptrend<0.001, relative risk (RR): 0.94 (95% confidence interval, 95% CI, 0.91-0.97) for every 5 kg/m2 increase]; there was no evidence of heterogeneity (Pheterogeneity=0.27). For advanced PCa, we observed a linear direct relationship with BMI (Ptrend=0.001, RR: 1.09 (95% CI 1.02-1.16) for every 5 kg/m2 increase); there was weak evidence of heterogeneity (Pheterogeneity=0.08). Omitting one study that contributed substantially to the heterogeneity yielded a pooled RR of 1.07 (95% CI 1.01-1.13) for every 5 kg/m2 increase (Pheterogeneity=0.26).

CONCLUSIONS

The quantitative summary of the accumulated evidence indicates that obesity may have a dual effect on PCa-a decreased risk for localized PCa and an increased risk for advanced PCa.

Body mass index in early and middle-late adulthood and risk of localised, advanced and fatal prostate cancer: a population-based prospective study

BACKGROUND

The relationships between body mass index (BMI) during early and middle-late adulthood and incidence of prostate cancer (PCa) by subtype of the disease (localised, advanced) and fatal PCa is unclear.

METHODS

A population-based cohort of 36,959 Swedish men aged 45-79 years was followed up from January 1998 through December 2008 for incidence of PCa (1530 localised and 554 advanced cases were diagnosed) and through December 2007 for PCa mortality (225 fatal cases).

RESULTS

From a competing-risks analysis, incidence of localised PCa was observed to be inversely associated with BMI at baseline (middle-late adulthood; rate ratio (RR) for 35 kg m(-2) when compared with 22 kg m(-2) was 0.69 (95% CI 0.52-0.92)), but not at age 30. For fatal PCa, BMI at baseline was associated with a nonstatistically significant increased risk (RR for every five-unit increase: 1.12 (0.88-1.43)) and BMI at age 30 with a decreased risk (RR for every five-unit increase: 0.72 (0.51-1.01)).

CONCLUSION

Our results indicate an inverse association between obesity during middle-late, but not early adulthood, and localised PCa. They also suggest a dual association between BMI and fatal PCa--a decreased risk among men who were obese during early adulthood and an increased risk among those who were obese during middle-late adulthood.

Investigative clinical study on prostate cancer part IV: exploring functional relationships of total testosterone predicting free testosterone and total prostate-specific antigen in operated prostate cancer patients

OBJECTIVES

To explore, in operated prostate cancer patients, functional relationships of total testosterone (tt) predicting free testosterone (ft) and total PSA.

PATIENTS AND METHODS

128 operated prostate cancer patients were simultaneously investigated for tt, ft and PSA before surgery. Patients were not receiving 5α-reductase inhibitors, LH-releasing hormone analogues and testosterone replacement treatment. Scatter plots including ft and PSA versus tt were computed in order to assess the functional relationship of the variables. Linear regression analysis of tt predicting ft and PSA was computed.

RESULTS

tt was a significant predictor of the response variable (ft) and different subsets of the patient population were assessed according to the ft to tt ratio. PSA was related to tt according to a nonlinear law. tt was a significant predictor of PSA according to an inversely nonlinear law and different significant clusters of the patient population were assessed according to the different constant of proportionality computed from experimental data.

CONCLUSIONS

In our prostate cancer population, ft was significantly predicted by tt according to a linear law, and the ft/tt ratio was a significant parameter for assessing the different clusters. Also, tt was a significant variable predicting PSA by a nonlinear law and different clusters of the patient population were assessed by the different constants of proportionality. As a theory, we explain the nonlinear relation of tt in predicting PSA as follows: (a) the number of androgen-independent prostate cancer cells increases as tumor volume and PSA serum levels rise, (b) the prevalence of androgen-independent cells producing a substance which inhibits serum LH, and (c) as a result lower levels of serum tt are detected.

Baseline serum testosterone in men treated with androgen deprivation therapy and radiotherapy for localized prostate cancer

INTRODUCTION

It is believed that men diagnosed with prostate cancer and a low baseline serum testosterone (BST) may have more aggressive disease, and it is frequently recommended they forego testosterone replacement therapy. We used two large Phase III trials involving androgen deprivation therapy and external beam radiation therapy to assess the significance of a BST.

METHODS AND MATERIALS

All patients with a BST and complete data (n = 2,478) were included in this analysis and divided into four categories: "Very Low BST" (VLBST) ≤16.5th percentile of BST (≤248 ng/dL; n = 408); "Low BST" (LBST) >16.5th percentile and ≤33rd percentile (>248 ng/dL but ≤314 ng/dL; n = 415); "Average BST" (ABST) >33rd percentile and ≤67th percentile (314-437 ng/dL; n = 845); and "High BST" (HBST) >67th percentile (>437 ng/dL; n = 810). Outcomes included overall survival, distant metastasis, biochemical failure, and cause-specific survival. All outcomes were adjusted for the following covariates: treatment arm, BST, age (<70 vs. ≥70), prostate-specific antigen (PSA; <10 vs. 10 ≤ PSA <20 vs. 20 ≤), Gleason score (2-6 vs. 7 vs. 8-10); T stage (T1-T2 vs. T3-T4), and Karnofsky Performance Status (60-90 vs. 100).

RESULTS

On multivariable analysis age, Gleason score, and PSA were independently associated with an increased risk of biochemical failure, distant metastasis and a reduced cause-specific and overall survival (p < 0.05), but BST was not.

CONCLUSIONS

BST does not affect outcomes in men treated with external beam radiation therapy and androgen deprivation therapy for prostate cancer.

Characteristics and outcome of prostate cancer with PSA <4 ng/ml at diagnosis: a population-based study

This population-based study aims to assess prognosis of prostate cancer diagnosed with prostate-specific antigen (PSA) levels <4 ng/ml in routine care. Materials and methods We compared prostate cancer patients with low PSA values (n=59) with other prostate cancer patients (n=1330) by logistic regression and the Cox model using data from the Geneva Cancer Registry. Results Patients with low PSA values more frequently had early-stage and well differentiated tumours. Nevertheless, 35% presented with aggressive tumour characteristics or metastases. After adjustment for other prognostic factors, prostate cancer-specific mortality was similar for both groups (hazard ratio: 1.1; 95%CI: 0.6-2.2). Conclusion We conclude that cancer with low PSA values at diagnosis is not indolent.

Association of Prostate Size and Tumor Grade in Korean Men with Clinically Localized Prostate Cancer

OBJECTIVES

To investigate the association of prostate size with aggressiveness of prostate cancer in Korean men who received radical retropubic prostatectomy (RRP) for clinically localized prostate cancer.

METHODS

We evaluated the association of RRP specimen weight and prostate volume measured by transrectal ultrasound (TRUS) with pathologic tumor grade, extraprostatic extension of disease, surgical margin status, and seminal vesicle invasion by reviewing data of 346 consecutive patients who underwent RRP for clinically localized prostate cancer at our institution without receiving preoperative radiation or hormonal treatment.

RESULTS

A strong correlation was observed between RRP specimen weight and TRUS-measured prostate volume (Spearman r = 0.76; P <0.001). After adjustment for multiple variables including age, body mass index, and preoperative prostate-specific antigen level, RRP specimen weight was observed to be significantly associated with presence of Gleason pattern 4 or greater at RRP in an inverse fashion (P = 0.03). Regarding other adverse pathologic features, prostate weight was also significantly inversely associated with extraprostatic extension of prostate cancer (P = 0.04) and surgical margin positivity (P = 0.002). When TRUS-measured prostate volume was applied in place of RRP specimen weight, results were the same.

CONCLUSIONS

Our data indicate that prostate size may be a useful predictor of tumor aggressiveness in Korean men with clinically localized prostate cancer. Further efforts should be made to elucidate actual mechanisms behind the association of prostate size and/or in vivo androgenicity with aggressiveness of prostate cancer.

Pathological outcomes and biochemical progression in men with T1c prostate cancer undergoing radical prostatectomy with prostate specific antigen 2.6 to 4.0 vs 4.1 to 6.0 ng/ml

PURPOSE

Recent studies have suggested that the cut point for recommending prostate biopsy among men with a normal digital rectal examination should be greater than 2.5 ng/ml as opposed to the more traditional greater than 4.0 ng/ml. We compared outcomes between men with clinical stage T1c disease undergoing radical prostatectomy who had a low vs slightly increased prostate specific antigen.

MATERIALS AND METHODS

The study population consisted of 2,896 men treated with radical prostatectomy between 1985 and 2004 at a tertiary care referral center with clinical stage T1c disease and a pre-biopsy prostate specific antigen between 2.6 and 6.0 ng/ml. Using multivariate analysis we evaluated the association between pre-biopsy prostate specific antigen 2.6 to 4.0 ng/ml (784) vs 4.1 to 6.0 ng/ml (2,112), and pathological outcomes and biochemical progression.

RESULTS

After adjusting for multiple clinical and pathological characteristics, lower preoperative serum prostate specific antigen values were associated with decreased odds of Gleason score 7 or greater in the surgical specimen (p = 0.004), positive surgical margins (p = 0.02) and extraprostatic extension (p = 0.001). There was no significant association between these preoperative prostate specific antigen groups and odds of seminal vesicle invasion (p = 0.47) or lymph node metastasis (p = 0.90). Among the 1,534 men with followup information available there was a trend for increased risk of biochemical progression associated with a higher preoperative prostate specific antigen, although this trend did not reach statistical significance (relative risk 1.48, 95% CI 0.69-3.19, p = 0.31).

CONCLUSIONS

In the current study of men with clinical stage T1c treated with radical prostatectomy a lower preoperative prostate specific antigen was associated with significantly more favorable pathological findings. Whether this degree of improved outcomes justifies the limitations associated with decreasing the prostate specific antigen cut point (eg increased biopsies performed and diagnosis of insignificant cancers) remains to be determined.

Are Findings from Studies of Obesity and Prostate Cancer Really in Conflict?

Recent studies on the association between obesity and prostate cancer appear to be in conflict. A recent prospective cohort study reported that the incidence of prostate cancer was lower among obese men under the age of 60 years and among those men with a family history of prostate cancer. Similarly, a case-control study found obesity was inversely associated with prostate cancer risk in men aged 40-64 years. However, several prospective cohort studies found that obese men are more likely to die from prostate cancer than non-obese men. Finally, two recent studies found that among men with prostate cancer, obese men were more likely to have a biochemical progression after surgery. We postulate that by closely examining the comparison groups used in these studies, these findings may, in fact, be in agreement. Specifically, this paradox within the literature may result from the possibility that obesity influences the development of aggressive (i.e., higher stage, higher grade, recurrence, death) and non-aggressive disease differently. We suggest that obesity may reduce the risk of non-aggressive disease but simultaneously increase the risk of aggressive disease. Finally, additional methodological issues are discussed that investigators need to be aware of to be able to draw inferences across studies of obesity and prostate cancer outcomes.

Predictive criteria for prostate cancer detection in men with serum PSA concentration of 2.0 to 4.0 ng/mL

OBJECTIVES

To assess the usefulness of measuring testosterone, free testosterone, and the free/total (f/t) prostate-specific antigen (PSA) ratio with the intention of reducing the number of unnecessary biopsies in the patients with PSA values between 2.0 and 4.0 ng/mL. Cancer detection is not rare among patients with PSA values between 2.0 and 4.0 ng/mL.

METHODS

A total of 171 men with serum PSA levels of 2.0 to 4.0 ng/mL were enrolled in this study. The f/t PSA ratio and total and free testosterone levels were quantified. All patients underwent transrectal ultrasound-guided biopsy. The cancer detection rate, clinical and pathologic features of the cancers detected, and the probability of cancer detection in relation to the f/t PSA ratio and total and free testosterone levels were estimated. Two-step statistical analysis was used for descriptive purposes and in the detection of cancer predictors. Statistical significance was set at P < or = 0.05.

RESULTS

The mean patient age was 63.3 years. Cancer was detected in 39 (22.8%) of the 171 patients. Only 15.4% of our patients had insignificant cancer. The f/t PSA ratio and total and free testosterone levels were significantly lower in the patients with prostate cancer (19.3%, 13.68 nmol/L, and 28.4 pmol/L, respectively; P < 0.001). The f/t PSA ratio and free testosterone were the strongest predictors of cancer detection (P < 0.001).

CONCLUSIONS

The results of our study have shown that an important number of cancers could be detected in the PSA range of 2.0 to 4.0 ng/mL. The great majority of cancers detected have the features of medically significant tumors. The combination of the f/t PSA ratio and free testosterone measurements may reveal those patients who require biopsy.

Prostate size and risk of high-grade, advanced prostate cancer and biochemical progression after radical prostatectomy: a search database study

PURPOSE

Prostate growth and differentiation are under androgenic control, and prior studies suggested that tumors that develop in hypogonadal men are more aggressive. We examined whether prostate weight was associated with tumor grade, advanced disease, or risk of biochemical progression after radical prostatectomy (RP).

PATIENTS AND METHODS

We evaluated the association of prostate weight with pathologic tumor grade, positive surgical margins, extracapsular disease, and seminal vesicle invasion using logistic regression and with biochemical progression using Cox proportional hazards regression among 1,602 men treated with RP between 1988 and 2003 at five equal-access medical centers, which composed the Shared Equal Access Regional Cancer Hospital (SEARCH) Database.

RESULTS

In outcome prediction models including multiple predictor variables, it was found that the predictor variable of prostate weight was significantly inversely associated with the outcomes of high-grade disease, positive surgical margins, extracapsular extension (all P < or = .004), and biochemical progression (comparing prostate weight < 20 v > or = 100 g: relative risk = 8.43; 95% CI, 2.9 to 24.0; P < .001). Similar associations were seen between preoperative transrectal ultrasound-measured prostate volume and high-grade disease, positive surgical margins, extracapsular extension (all P < or = .005), seminal vesicle invasion (P = .07), and biochemical progression (P = .06).

CONCLUSION

Men with smaller prostates had more high-grade cancers and more advanced disease and were at greater risk of progression after RP. These results suggest that prostate size may be an important prognostic variable that should be evaluated for use pre- and postoperatively to predict biochemical progression.

THE PROSTATIC SPECIFIC ANTIGEN ERA IS ALIVE AND WELL: PROSTATIC SPECIFIC ANTIGEN AND BIOCHEMICAL PROGRESSION FOLLOWING RADICAL PROSTATECTOMY

PURPOSE

Prostate specific antigen (PSA) has been shown to predict the presence of prostate cancer on biopsy, pathological stage, and biochemical progression following primary therapy. A recent study found only a weak association between PSA and tumor volume in the radical prostatectomy (RP) specimen and concluded that the PSA era is over. We examined the association between PSA and clinical progression in men undergoing RP.

MATERIALS AND METHODS

The study population consisted of 2,312 men treated with RP between 1992 and 2004 by a single surgeon. We evaluated the association between preoperative PSA and biochemical progression on multivariate analysis.

RESULTS

Men with higher preoperative PSA concentrations had higher grade cancers in the biopsy and RP specimen, and more adverse pathological features. After adjusting for the clinical covariates of age, race, grade, stage, and year of surgery, preoperative PSA was significantly associated with the risk of biochemical progression. When only men with PSA less than 10 ng/ml were examined, PSA remained a significant predictor of biochemical progression on multivariate analysis (RR 1.30, 95% CI 1.18 to 1.44, p <0.001). For each 2-point increase in PSA, the risk of biochemical progression increased approximately 2-fold.

CONCLUSIONS

Preoperative PSA was significantly associated with high grade disease and adverse pathological findings. After adjusting for clinical covariates, PSA was significantly associated with the risk of biochemical progression, even in men with PSA less than 10 ng/ml. Despite multiple limitations, PSA remains the best prostate cancer tumor marker available.

Preoperative PSA and progression-free survival after radical prostatectomy for Stage T1c disease

OBJECTIVES

To examine biochemical progression-free survival (PFS) rates as a function of preoperative prostate-specific antigen (PSA) in patients with clinical Stage T1c prostate cancer treated with radical prostatectomy. Controversy exists about whether performing prostate biopsies for PSA levels in the 2.6 to 4.0 ng/mL range provides a PFS advantage compared with detection at higher PSA ranges.

METHODS

A total of 2804 men with clinical Stage T1c prostate cancer were treated with radical retropubic prostatectomy and monitored prospectively. The study parameters included preoperative PSA level, pathologic tumor stage, and Gleason grade. Patients were grouped into four clinically relevant strata according to their preoperative PSA level: 2.6 to 4.0, 4.1 to 7.0, 7.1 to 10.0, and greater than 10 ng/mL. The primary outcome was the 10-year actuarial biochemical PFS estimate generated using the Kaplan-Meier method. We compared the strata using the log-rank test. Cancer progression rates were compared using the Cochran Armitage test for trend. The chi-square test was used to compare the pathologic parameters among the PSA strata.

RESULTS

Of the men with a preoperative PSA level of 2.6 to 4.0, 4.1 to 7.0, 7.1 to 10.0, and greater than 10.0 ng/mL, 81%, 74%, 72%, and 60%, respectively, had organ-confined disease (P = 0.001) and 23%, 28%, 35%, and 47%, respectively, had a pathologic Gleason grade of 7 or greater (P = 0.001). The corresponding 10-year PFS estimates were 88%, 80%, 76%, and 61% (P = 0.0001, for trend).

CONCLUSIONS

Among men with clinical Stage T1c prostate cancer, those with a PSA level of 2.6 to 4.0 ng/mL had the greatest rate of organ-confined disease, lowest pathologic Gleason grade, and greatest 10-year PFS rate.

Serum pro-prostate specific antigen preferentially detects aggressive prostate cancers in men with 2 to 4 ng/ml prostate specific antigen

PURPOSE

Pro forms of prostate specific antigen (PSA) have been reported to be more cancer specific markers of prostate cancer than total PSA and they also may preferentially detect the more aggressive forms of the disease.

MATERIALS AND METHODS

Research immunoassays with high specificity for pro-PSA forms were used to study 1091 retrospective serum specimens, including 555 with 2 to 4 and 536 with 4 to 10 ng/ml PSA, from men enrolled in prostate cancer screening studies who underwent prostate biopsy.

RESULTS

In the 2 to 4 ng/ml PSA range the ratio of pro- to free-PSA (percent pro-PSA) using a cutoff of 1.8% for recommending prostate biopsy detected 90% of cancers, including 16 of 16 extracapsular tumors and 28 of 29 tumors with a pathology Gleason score of 7 or greater, while avoiding 19% of unnecessary biopsies. Serum percent pro-PSA was significantly increased for Gleason score 7 or greater vs less than 7 (p = 0.0018). In the PSA range of 4 to 10 ng/ml percent pro-PSA had the highest cancer specificity, avoiding 31% of unnecessary biopsies, while detecting 34 of 35 cancers with a pathology Gleason score of 7 or greater and 29 of 31 extracapsular tumors. Neither percent free PSA nor complexed PSA enhanced the detection of aggressive cancers in the 4 to 10 ng/ml PSA range.

CONCLUSIONS

Percent pro-PSA was superior to percent free and calculated complexed PSA for the detection of prostate cancer in the PSA range of 2 to 10 ng/ml and it had selectivity for detecting more aggressive cancers, as indicated by Gleason score 7 or greater and/or extracapsular tumor extension.

Biochemical outcome after radical prostatectomy among men with normal preoperative serum prostate-specific antigen levels

BACKGROUND

Recent studies have shown that a significant number of men with normal prostate-specific antigen (PSA) levels have prostate carcinoma. Whether malignancies in such men are associated with better outcomes is unclear. The authors compared the risk of biochemical failure after radical prostatectomy (RP) between men with normal PSA levels and men with elevated PSA levels.

METHODS

Data were examined from 1582 men who underwent RP between 1988 and 2002 at 1 of 5 equal-access medical centers. Patients were segregated into groups based on serum PSA levels (with stratification according to age-specific reference ranges). Clinical and pathologic characteristics and biochemical outcome data were compared across groups using analyses of variance, log-rank tests, and Cox proportional hazards analysis.

RESULTS

Men who had normal PSA levels had significantly fewer high-grade tumors compared with men who had higher PSA levels (P < 0.001). The former group had a significantly decreased incidence of positive surgical margins, extracapsular disease, seminal vesicle invasion, and lymph node involvement (P < 0.001). On multivariate analysis, only serum PSA level (P < 0.001) and biopsy Gleason score (P < 0.001) predicted the time to disease recurrence. When only men with serum PSA levels < 10 ng/mL were examined, PSA level treated as a continuous variable remained a significant predictor of time to biochemical failure (P = 0.02).

CONCLUSIONS

Men who had normal PSA levels had significantly fewer high-grade tumors and significantly better biochemical outcomes after undergoing RP compared with men who had elevated PSA levels. Overall, men with normal PSA levels who undergo RP represent a favorable risk group.