Population-based study of pelvic lymph node positivity in clinically localized prostate cancer: a study comparing African Americans and whites

Analysis of impact of age and race on biochemical control after radiotherapy in different prostate cancer settings

OBJECTIVES

To provide a single-institution analysis of the impact of age and race on biochemical control after radiotherapy (RT) administered in different prostate cancer scenarios. Age and race are among the most controversial prognostic factors in determining outcome after RT. Proper understanding of these prognostic factors can assist in both treatment decision-making and the general understanding of the natural history of prostate cancer.

METHODS

The records of 527 consecutive nonmetastatic patients undergoing RT at a single institution and for whom demographic, disease, treatment, and follow-up information were available were reviewed. The cohort was divided into two categories: locally advanced/localized (458 patients) and postprostatectomy (69 patients). Biochemical failure-free survival (BFFS) curves were compared within each group to determine the influence of age and race on biochemical control.

RESULTS

BFFS curves for the entire study population did not reveal any statistically significant difference when separated by age (younger than 60 years versus 60 to 69 years versus 70 years or older; 4-year BFFS 75% versus 70% versus 72%, respectively; P = 0.773) or by race (African American versus white; 4-year BFFS 74% versus 70%, respectively; P = 0.469). Additionally, no statistically significant differences were observed as a function of stage or age within either category (intact prostate or postprostatectomy).

CONCLUSIONS

Age and race did not, in our study, independently influence biochemical control after RT for nonmetastatic prostate cancer. On the basis of the results of this study, age and race should not be used as independent factors in treatment decision-making and in patient counseling concerning prostate cancer.

Is Hispanic Race an Independent Risk Factor for Pathological Stage in Patients Undergoing Radical Prostatectomy?

PURPOSE

Hispanic-Americans are the most rapidly growing population in the United States. Although many studies have assessed differences in pathological stage at radical prostatectomy between white and black American men, to our knowledge none has assessed it in Hispanic men. We compared pathological stage at radical prostatectomy in contemporaneous groups of Hispanic and white American men.

MATERIALS AND METHODS

A total of 141 consecutive Hispanic and 314 consecutive white American men underwent radical retropubic prostatectomy for clinically localized prostate cancer from 1995 to 2002 at a single institution, as performed by one of us (ETG or MCB). Preoperative prostate specific antigen (PSA), age at diagnosis, race, clinical stage, biopsy and specimen Gleason score, pathological stage, specimen volume and calculated specimen PSA density were collected for each patient. Data were compared using standard statistical methods.

RESULTS

Biopsy Gleason score, biopsy Gleason score distribution, specimen Gleason score, specimen Gleason distribution, pathological stage, calculated specimen PSA density, Gleason score change from biopsy to specimen and specimen prostate volume did not differ statistically between Hispanic and white men. Mean age and median preoperative PSA were statistically significantly higher in Hispanic vs white men (62.1 vs 59.5 years and 6.6 vs 5.4 ng/ml, respectively). In addition, no differences in the incidence of positive surgical margins, nonorgan confined disease, seminal vesicle invasion or positive lymph nodes were found between Hispanic and white men undergoing radical prostatectomy.

CONCLUSIONS

This study shows that in contemporaneously treated groups of Hispanic and white men at the same institution pathological stage was similar between the groups. To our knowledge this is the largest comparison of surgically treated prostate cancer between these 2 groups. Further followup in terms of PSA outcome in these groups is planned.

Clinical features and treatment outcome of Hispanic men with prostate cancer following external beam radiotherapy

PURPOSE

We retrospectively analyzed the clinical characteristics and outcomes of Hispanic men compared with other groups who underwent radiotherapy alone for localized or locally advanced prostate cancer.

MATERIALS AND METHODS

Between April 1987 and January 1998, 964 men who underwent full dose external beam radiotherapy alone for localized or locally advanced prostate cancer were included in the study. Patient medical records were reviewed for pertinent information.

RESULTS

Of the 964 men 810 were non-Hispanic white, 54 were Hispanic and 86 were black Americans. The most significant difference among the groups was in the proportion of patients who presented with initial prostate specific antigen (PSA) greater than 20 ng/ml (22% of Hispanic vs 11% of white men, p = 0.0012). In addition, 17% of Hispanic men had a Gleason score of 8 or greater compared with 11% of white men (p = 0.0265). A greater proportion of Hispanic patients also had a less favorable posttreatment PSA nadir of greater than 1 ng/ml compared with white patients, (44% vs 26%, p = 0.0214), which may have translated into a trend toward a lower 5-year disease-free survival rate in Hispanics vs white men (52% vs 65%, p = 0.07).

CONCLUSIONS

Hispanic men presented with higher PSA and higher grade prostate cancer than white men. Furthermore, a higher percent of Hispanic men had a PSA nadir of 1 ng/ml or greater after radiotherapy, which may have been responsible for their trend toward a decreased 5-year disease-free survival rate compared with white men. Improved screening and early detection may improve disease-free survival in Hispanic men with localized prostate cancer.

Effect of race on biochemical disease-free outcome in patients with prostate cancer treated with definitive radiation therapy in an equal-access health care system: radiation oncology report of the Department of Defense Center for Prostate Disease Research

PURPOSE

To report on the first collaboration of the Department of Defense Center for Prostate Disease Research concerned with the relationship between African American race and biochemical disease-free outcomes after definitive radiation therapy.

MATERIALS AND METHODS

Information from the medical records of 1,806 patients (1,349 white, 343 African American, 42 of "other" races, and 72 of "unknown" races) treated with definitive radiation therapy between 1973 and 2000 was reviewed. Patients receiving adjuvant hormonal therapy or postoperative adjuvant or salvage radiation therapy were excluded. Biochemical failure was calculated in over 96% of cases by using ASTRO criteria; patients with fewer than three follow-up visits were considered to have biochemical failure with a prostate-specific antigen (PSA) value more than 10-fold the previous value or with any value greater than 50.0 ng/mL. Median radiation therapy doses were similar. The median follow-up was 58.4 months. Kaplan-Meier tests, Cox proportional hazards regression analysis, and log-rank tests were used for data analysis.

RESULTS

There was no statistically significant difference in biochemical disease-free survival according to race when patients were stratified according to T stage. African American race conferred a negative prognosis for patients with lesions of Gleason biopsy score 7 (P =.004) but not for patients with lesions of Gleason score 2-4 (P =.14), 5-6 (P =.79), or 8-10 (P =.86). Similarly, African American race conferred a negative prognosis in patients with PSA values of 20.1-50.0 ng/mL (P =.01) at presentation but not in patients with PSA values less than or equal to 4.0 ng/mL (P =.84), 4.1-10.0 ng/mL (P =.71), 10.1-20.0 ng/mL (P =.75), or above 50.0 ng/mL (P =.15) at presentation. At multivariate analysis, race was not a statistically significant predictor of outcome.

CONCLUSION

In the equal-access health care system of the Department of Defense, African American race is not associated with a consistently negative prognosis in patients treated with definitive radiation therapy for prostate cancer. Race appears to confer a negative prognosis only in patients with advanced disease at presentation.

Impact of race on prostate-specific antigen outcome after radical prostatectomy for clinically localized adenocarcinoma of the prostate

PURPOSE

To compare prostate-specific antigen (PSA) outcome after radical prostatectomy (RP) for prostate cancer in African-American and white men using previously established risk groups.

PATIENTS AND METHODS

Between 1989 and 2000, 2,036 men (n = 162 African-American men, n = 1,874 white men) underwent RP for clinically localized prostate cancer. Using pretreatment PSA, Gleason score, clinical T stage, and percentage of positive biopsy specimens, patients were stratified into low- and high-risk groups. For each risk group, PSA outcome was estimated using the actuarial method of Kaplan and Meier. Comparisons of PSA outcome between African-American and white men were made using the log-rank test.

RESULTS

The median age and PSA level for African-American and white men were 60 and 62 years old and 8.8 and 7.0 ng/mL, respectively. African-Americans had a statistically significant increase in PSA (P =.002), Gleason score (P =.003), clinical T stage (P =.004), and percentage of positive biopsy specimens (P =.04) at presentation. However, there was no statistical difference in the distribution of PSA, clinical T stage, or Gleason score between racial groups in the low- and high-risk groups. The 5-year estimate of PSA outcome was 87% in the low-risk group for all patients (P =.70) and 28% versus 32% in African-American and white patients in the high-risk group (P =.28), respectively. Longer follow-up is required to confirm if these results are maintained at 10 years.

CONCLUSION

Even though African-American men presented at a younger age and with more advanced disease compared with white men with prostate cancer, PSA outcome after RP when controlled for known clinical predictive factors was not statistically different. This study supports earlier screening in African-American men.

Is it necessary to do staging pelvic lymph node dissection for T1c prostate cancer?

The necessity of pelvic lymph node dissection has been questioned in recent years as a result of improved pre-treatment staging based on clinical and pathologic factors. Accurate evaluation of nodal status allows rational selection of therapy and improved outcomes. Nevertheless, lymph node dissection may play a role even in patients with low stage disease (clinical T1c) despite an overall low risk for metastases. Herein we discuss recent advances in the evaluation of lymph nodes in stage T1c prostate cancer with respect to accurate prediction, radiologic imaging, molecular characterization, and operative considerations.

Equivalent racial outcome after conformal radiotherapy for prostate cancer: a single departmental experience

PURPOSE

African-American (AA) men with prostate cancer present with advanced disease, relative to white (W) men. This report summarizes our clinical and biochemical control (bNED) rates after conformal radiotherapy (RT). In particular, we aim to characterize any race-based outcome differences seen after comparable treatment.

PATIENTS AND METHODS

We reviewed 893 patients (418 AA and 475 W) with clinically localized prostate cancer treated between 1988 and 1997. Neoadjuvant hormonal blockade was used in 22.5% of cases, and all patients received conformal RT to a median dose of 68 Gy (range, 60 to 74.8 Gy). Biochemical failure was defined according to the American Society of Therapeutic Radiology and Oncology consensus definition. Median follow-up was 24 months (range, 1 to 114 months).

RESULTS

The 5-year actuarial survival, disease-free survival, and bNED rates for the entire population were 80.5%, 70.0%, and 57.6%, respectively. When classified by prognostic risk category, the 5-year actuarial bNED rates were 78.7% for favorable, 57.7% for intermediate, and 39.8% for unfavorable category patients. AA men presented at younger ages and with more advanced disease. Controlled for prognostic risk category, AA and W men had similar 5-year actuarial bNED rates in favorable (78% v 79%, P: = .91), intermediate (52% v 62%, P: =.44), and unfavorable categories (36% v 45%, P: = .09). Race was not an independent prognostic factor (P: = .36).

CONCLUSION

Conformal RT is equally effective for AA and W patients. More research is needed in order to understand and correct the advanced presentations in AA men. These data suggest a need for early screening in AA populations.

Multivariate analysis of race and adverse pathologic findings after radical prostatectomy

OBJECTIVES

Adverse pathologic features that predict disease recurrence after radical prostatectomy (RP) include positive surgical margins, non-organ-confined disease, and seminal vesicle invasion. Given that black men have a higher incidence of, and mortality from, prostate cancer compared with white men, we sought to determine whether race was an independent predictor of adverse pathologic findings among men who underwent RP at an equal access health care center. Results from previous studies evaluating whether race predicts positive surgical margins have been conflicting. No prior studies have evaluated whether race is an independent predictor of non-organ-confined disease or seminal vesicle invasion.

METHODS

A retrospective survey of 274 patients (126 black, 148 white) who underwent RP at the West Los Angeles Veterans Affairs Medical Center between 1991 and 1999 was undertaken. Multivariate analysis was used to determine the preoperative clinical variables that were most significant in predicting positive surgical margins, non-organ-confined disease, and seminal vesicle invasion. The preoperative variables analyzed were race, age, serum prostate-specific antigen, clinical stage, and biopsy Gleason score.

RESULTS

No differences in the incidence of positive surgical margins, non-organ-confined disease, or seminal vesicle invasion were found between black and white men undergoing RP. After controlling for the preoperative variables of age, serum prostate-specific antigen level, clinical stage, and biopsy Gleason score, race was not an independent predictor of positive surgical margins, non-organ-confined disease, or seminal vesicle invasion.

CONCLUSIONS

This is the first study to show that black race was not an independent predictor of non-organ-confined disease or seminal vesicle invasion among patients undergoing RP. Furthermore, race was not an independent predictor of positive surgical margins.

Per-operative frozen section examination of pelvic nodes is unnecessary for the majority of clinically localized prostate cancers in the prostate-specific antigen era

BACKGROUND

The incidence of unsuspected lymph node metastasis seems to be decreasing in the prostate-specific antigen (PSA) era. It remains controversial as to whether routine pelvic lymph node dissection and per-operative frozen section examination should be performed. In addition, it is still unclear whether an aggressive approach to local disease by surgery or irradiation confers survival benefits on stage D1 patients.

METHODS

Eighty-eight consecutive patients with clinically localized prostate cancer who underwent pelvic lymph node dissection prior to radical prostatectomy during the period between 1985 and 1998 were analyzed. The incidence of lymph node metastases after 1992 was compared with that before 1992. Sensitivity and specificity of frozen section examination was assessed. Progression-free survival and cause-specific survival curves of node-positive patients who underwent radical prostatectomy were estimated by the Kaplan-Meier method.

RESULTS

Six of 17 patients (35.3%) treated before 1992 and five of 71 patients (7.0%) treated after 1992 showed unsuspected lymph node metastasis (P = 0.0059). Eight of 11 node-positive patients underwent radical prostatectomy and two have so far demonstrated clinical progression and cancer death with a median follow-up period of 63 months. The 5 year progression-free rate and the cause-specific survival rate for these patients were 71.4 and 85.7%, respectively. Sensitivity of frozen section examination for micrometastasis and gross-metastasis cases, respectively, was 3/6 (50%) and 4/4 (100%), while specificity was 85/85 (100%).

CONCLUSIONS

The incidence of unsuspected lymph node metastases has been significantly decreased in the PSA era. Frozen section examination of pelvic nodes can be omitted and radical prostatectomy is an acceptable choice of treatment in patients without macroscopically apparent nodal metastases.

Race is not an independent predictor of biochemical recurrence after radical prostatectomy in an equal access medical center

OBJECTIVES

To compare the racial differences in clinical and pathologic features between black and white men who underwent radical prostatectomy (RP) in an equal access health care center and to determine whether race is an independent predictor of biochemical recurrence.

METHODS

A retrospective survey of 273 patients (125 black, 148 white) who underwent RP at the West Los Angeles Veterans Affairs Medical Center between 1991 and 1999 was undertaken. Patients were analyzed for racial differences in age at diagnosis, clinical stage, preoperative serum prostate-specific antigen (PSA), and Gleason score of the prostate biopsy specimens. Surgical specimens were studied to determine pathologic stage, Gleason score, incidence of seminal vesicle invasion, positive surgical margins, capsular penetration, and pelvic lymph node involvement. Patients were followed for PSA recurrence (greater than 0.2 ng/mL). Multivariate analysis was used to determine the clinical and pathologic variables that were significant in predicting biochemical recurrence after RP and to determine whether race was an independent predictor of biochemical failure.

RESULTS

No significant differences were found between black and white men in the preoperative factors (clinical stage, age at diagnosis, biopsy Gleason score, and serum PSA) or in the pathologic features of the RP specimens (Gleason score, pathologic stage, incidence of positive surgical margins, capsular penetration, seminal vesicle invasion, or lymph node involvement). In addition, no differences were found between black and white men in the PSA recurrence rates after RP using Kaplan-Meier survival curves (P = 0.651). Multivariate analysis revealed that serum PSA (P = 0.010), biopsy Gleason score (P = 0. 003), younger age (P = 0.010), surgical Gleason score (P = 0.005), and lymph node involvement (P = 0.022) were all independent predictors of biochemical recurrence. Race was not a significant predictor of biochemical failure in multivariate analysis (P = 0. 199).

CONCLUSIONS

In an equal access medical care facility, no differences were evident between black and white men in the preoperative clinical factors or the pathologic features of the RP specimens. In addition, no differences were observed in the PSA recurrence rates after RP. Serum PSA, biopsy Gleason score, younger age, surgical Gleason score, and lymph node involvement were all independent predictors of biochemical recurrence. Race was not an independent predictor of biochemical recurrence.

Prostate cancer biochemical recurrence stage for stage is more frequent among African-American than white men with locally advanced but not organ-confined disease

OBJECTIVES

To determine whether outcome differences between African-American men (AAM) and white men with prostate cancer (PCa) will still be present if we control for stage in a large cohort of men. It is well established that AAM have a worse outcome from PCa than white men.

METHODS

We examined 848 consecutive patients who underwent radical prostatectomy at Wayne State University, Karmanos Cancer Institute, between 1991 and 1995. The mean follow-up was 34 months (range 1.5 to 75). We included men with Gleason score 7 (4 + 3) with those men with Gleason score 8 to 10 for racial/ethnic comparisons.

RESULTS

AAM and white men diagnosed with organ-confined PCa demonstrated similar prostate-specific antigen (PSA) levels, Gleason grade, and biochemical recurrence. However, AAM diagnosed with non-organ-confined disease demonstrated higher PSA levels and a higher incidence of recurrence than did white men with non-organ-confined disease. There was a trend toward AAM having a greater proportion of high-grade lesions than white men when PCa was not organ confined. The evidence suggests that the difference in recurrence among AAM versus white men is based on pretreatment PSA, grade, extracapsular extension, and positive surgical margins. Seminal vesicle invasion predicted a worse prognosis equally for both AAM and white men.

CONCLUSIONS

A difference in biochemical recurrence was not detected between AAM and white men with organ-confined PCa after radical prostatectomy. PSA was higher in AAM than in white men with pathologically locally advanced PCa, and the biochemical recurrence was greater. AAM had a greater percentage of high Gleason grade lesions compared with white men, and this difference approached statistical significance. We hypothesize that AAM have a more rapid growth rate of PCa, which may be responsible for these clinical findings. Further investigations of the biology of PCa are needed to understand these findings.