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Park JS, Koo KC, Choi IY, Lee JY, Hong JH, Kim CS, Lee HM, Hong SK, Byun SS, Rha KH, Chung BH, Lee KS. Stratification based on adverse laboratory/pathological features for predicting overall survival in patients undergoing radical prostatectomy: A K-CaP registry-based analysis. Medicine (Baltimore) 2019; 98:e17931. [PMID: 31702677 PMCID: PMC6855645 DOI: 10.1097/md.0000000000017931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
When making clinical decisions concerning additional treatment for patients who have undergone radical prostatectomy (RP), adverse laboratory/pathological features are considered major factors. We investigated and compared the prognostic efficacy of adverse laboratory/pathological features in predicting overall survival (OS) and biochemical failure (BCF) in these patients.The Korean Prostate Cancer Database was used to identify patients undergoing RP between May 2001 and April 2013. Patients with incomplete clinicopathological data or positive lymphadenectomy results were excluded. Finally, 4486 patients included in the final analysis were categorized based on their adverse laboratory/pathological features.Adverse pathological features and detectable prostate-specific antigen (PSA) levels 6 weeks after surgery were observed in 1977 (44.1%) and 634 (14.1%) patients, respectively. PSA levels, pathological Gleason score ≥8, adverse pathological features [positive surgical margin (PSM), seminal vesicle invasion (SVI), and extracapsular extension (ECE)], and adverse laboratory features (detectable PSA levels after 6 weeks) together were significant predictors of BCF-free survival (BCFFS). SVI was identified as a predictor of OS. Additionally, patients with ECE, PSM, and detectable PSA levels after 6 weeks, but without SVI, showed similar OS to those without ECE, PSM, and detectable PSA levels after 6 weeks and with SVI (log-rank test, P = .976).We successfully stratified patients based on adverse laboratory/pathological features after RP and demonstrated that these are important prognostic factors for OS and BCFFS. Additionally, we identified the criteria for selecting appropriate patients for undergoing additional treatment based on OS and BCFFS.
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Affiliation(s)
- Jee Soo Park
- Department of Urology, Yonsei University College of Medicine
| | - Kyo Chul Koo
- Department of Urology, Yonsei University College of Medicine
| | - In Young Choi
- Graduate School of Management and Policy, Catholic University
| | - Ji Youl Lee
- Department of Urology, Seoul St. Mary's Hospital, Catholic University
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine
| | - Choung-Soo Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Sung Kyu Hong
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Koon Ho Rha
- Department of Urology, Yonsei University College of Medicine
| | - Byung Ha Chung
- Department of Urology, Yonsei University College of Medicine
| | - Kwang Suk Lee
- Department of Urology, Yonsei University College of Medicine
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Hwang WL, Tendulkar RD, Niemierko A, Agrawal S, Stephans KL, Spratt DE, Hearn JW, Koontz BF, Lee WR, Michalski JM, Pisansky TM, Liauw SL, Abramowitz MC, Pollack A, Moghanaki D, Anscher MS, Den RB, Zietman AL, Stephenson AJ, Efstathiou JA. Comparison Between Adjuvant and Early-Salvage Postprostatectomy Radiotherapy for Prostate Cancer With Adverse Pathological Features. JAMA Oncol 2018; 4:e175230. [PMID: 29372236 PMCID: PMC5885162 DOI: 10.1001/jamaoncol.2017.5230] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/16/2017] [Indexed: 11/14/2022]
Abstract
Importance Prostate cancer with adverse pathological features (ie, pT3 and/or positive margins) after prostatectomy may be managed with adjuvant radiotherapy (ART) or surveillance followed by early-salvage radiotherapy (ESRT) for biochemical recurrence. The optimal timing of postoperative radiotherapy is unclear. Objective To compare the clinical outcomes of postoperative ART and ESRT administered to patients with prostate cancer with adverse pathological features. Design, Setting, and Participants This multi-institutional, propensity score-matched cohort study involved 1566 consecutive patients who underwent postprostatectomy ART or ESRT at 10 US academic medical centers between January 1, 1987, and December 31, 2013. Propensity score 1-to-1 matching was used to account for covariates potentially associated with treatment selection. Data were collected from January 1 to September 30, 2016. Data analysis was conducted from October 1, 2016, to October 21, 2017. Main Outcomes and Measures Freedom from postirradiation biochemical failure, freedom from distant metastases, and overall survival. All outcomes were measured from date of surgery to address lead-time bias. Results Of 1566 patients, 1195 with prostate-specific antigen levels of 0.1 to 0.5 ng/mL received ESRT and 371 patients with prostate-specific antigen levels lower than 0.1 ng/mL received ART. The median age (interquartile range) was 60 (55-65) years. After propensity score matching, the median (interquartile range) follow-up after surgery was similar between the ESRT and ART groups (73.3 [44.9-106.6] months vs 65.8 [40-107] months; P = .22). Adjuvant RT, compared with ESRT, was associated with higher freedom from biochemical failure (12-year actuarial rates: 69% [95% CI, 60%-76%] vs 43% [95% CI, 35%-51%]; effect size, 26%), freedom from distant metastases (95% [95% CI, 90%-97%] vs 85% [95% CI, 76%-90%]; effect size, 10%), and overall survival (91% [95% CI, 84%-95%] vs 79% [95% CI, 69%-86%]; effect size, 12%). Adjuvant RT, lower Gleason score and T stage, nodal irradiation, and postoperative androgen deprivation therapy were favorable prognostic features on multivariate analysis for biochemical failure. Sensitivity analysis demonstrated that the decreased risk of biochemical failure associated with ART remained significant unless more than 56% of patients in the ART group were cured by surgery alone. This threshold is greater than the estimated 12-year freedom from biochemical failure rate of 33% to 52% after radical prostatectomy alone, as determined by a contemporary dynamic nomogram. Conclusions and Relevance Adjuvant RT, compared with ESRT, was associated with reduced biochemical recurrence, distant metastases, and death for high-risk patients, pending prospective validation. These findings suggest that a greater proportion of patients with prostate cancer who have adverse pathological features may benefit from postprostatectomy ART rather than surveillance followed by ESRT.
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Affiliation(s)
- William L. Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rahul D. Tendulkar
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shree Agrawal
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kevin L. Stephans
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Jason W. Hearn
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Bridget F. Koontz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - W. Robert Lee
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | - Stanley L. Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois
| | | | - Alan Pollack
- Department of Radiation Oncology, University of Miami, Miami, Florida
| | - Drew Moghanaki
- Department of Radiation Oncology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Mitchell S. Anscher
- Department of Radiation Oncology, Virginia Commonwealth University Medical Center, Richmond
| | - Robert B. Den
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anthony L. Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J. Stephenson
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Bhindi B, Carlson RE, Mason RJ, Schulte PJ, Gettman MT, Frank I, Tollefson MK, Thompson RH, Boorjian SA, Leibovich BC, Karnes RJ. Long-term Follow-up of a Matched Cohort Study Evaluating the Role of Adjuvant Radiotherapy for Organ-confined Prostate Cancer With a Positive Surgical Margin. Urology 2017; 109:145-152. [DOI: 10.1016/j.urology.2017.06.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/01/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
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Buscariollo DL, Drumm M, Niemierko A, Clayman RH, Galland-Girodet S, Rodin D, Feldman AS, M Dahl D, McGovern FJ, F Olumi A, Eidelman A, Shipley WU, Zietman AL, Efstathiou JA. Long-term results of adjuvant versus early salvage postprostatectomy radiation: A large single-institutional experience. Pract Radiat Oncol 2016; 7:e125-e133. [PMID: 28274403 DOI: 10.1016/j.prro.2016.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/05/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to evaluate freedom from biochemical failure (FFBF), freedom from androgen deprivation therapy (FFADT), freedom from distant metastases (FFDM), and overall survival (OS) after adjuvant radiation therapy (ART) versus early salvage radiation therapy (ESRT) in men with prostate cancer and adverse pathologic features (pT3 and/or positive surgical margins). METHODS AND MATERIALS Of 718 patients consecutively treated with postoperative radiation therapy (RT) for prostate cancer between 1992 and 2013, we retrospectively identified 171 men receiving ART and 230 receiving ESRT (RT delivered at a prostate-specific antigen level ≤0.5 ng/mL) who had adverse pathologic features. Postirradiation FFBF (BF was defined as prostate-specific antigen level rise to ≥0.2 ng/mL), FFADT, FFDM, and OS were compared using Kaplan-Meier and Cox regression methods. Propensity score (PS)-matching was performed to estimate treatment effects while accounting for covariates predicting treatment allocation. RESULTS Median follow-up was 7.4 and 8.0 years for patients treated with ART and ESRT, respectively. Ten-year FFBF (69% vs 56%, P = .003) and 10-year FFADT (88% vs 81%, P = .046) rates were higher after ART; however, FFDM and OS did not significantly differ. After PS-matching, ART was associated with improved FFBF (P < .0001), FFADT (P = .0001), and FFDM (P = .02). Findings were confirmed in multivariable analyses in unmatched and PS-matched cohorts. Sensitivity analyses showed that FFBF benefit associated with ART lost statistical significance only after 38% of ART patients were assumed to have been cured by surgery and excluded from the model. This corresponds to the upper bound of patients with adverse pathologic features who did not recur after observation in prior randomized trials. CONCLUSIONS Postoperative RT confers excellent long-term cancer control. These results suggest ART may be associated with improved FFBF, FFADT, and FFDM, but comparable OS. Given the retrospective study design, these findings should be interpreted with caution. Optimal timing of postoperative RT further awaits results of ongoing trials.
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Affiliation(s)
- Daniela L Buscariollo
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Drumm
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis J McGovern
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Aria F Olumi
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alec Eidelman
- Tufts University School of Dental Medicine, Boston, Massachusetts
| | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anthony L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
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National Trends in the Recommendation of Radiotherapy After Prostatectomy for Prostate Cancer Before and After the Reporting of a Survival Benefit in March 2009. Clin Genitourin Cancer 2015; 13:e167-72. [DOI: 10.1016/j.clgc.2014.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/01/2014] [Accepted: 12/01/2014] [Indexed: 11/18/2022]
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Sineshaw HM, Gray PJ, Efstathiou JA, Jemal A. Declining Use of Radiotherapy for Adverse Features After Radical Prostatectomy: Results From the National Cancer Data Base. Eur Urol 2015; 68:768-74. [PMID: 25896124 DOI: 10.1016/j.eururo.2015.04.003] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 04/01/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patterns of postoperative radiotherapy (RT) use in prostate cancer (PCa) after the publication of major randomized trials have not been well characterized. OBJECTIVE To describe patterns of postoperative RT use after radical prostatectomy (RP) in patients with adverse pathologic features in the United States. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of 97 270 patients with PCa diagnosed between 2005 and 2011 whose presentation and outcomes were recorded in the National Cancer Data Base. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Temporal changes in receipt of postoperative RT and factors associated with receipt of this treatment using the Cochran-Armitage trend test and multiple logistic regression, respectively. RESULTS AND LIMITATIONS Between 2005 and 2011, receipt of postoperative RT decreased steadily from 9.1% to 7.3% (ptrend<0.001). Use of RT with or without androgen deprivation therapy monotonically decreased with advancing age from 8.5% in patients aged 18-59 yr to 6.8% in patients aged 70-79 yr (ptrend<0.001). Receipt of RT was higher at community cancer programs compared with teaching/research centers (14% vs 7.3%; odds ratio [OR]: 2.16; p<0.001), in those with pT3-4 disease and positive margins compared with those with pT3-4 and negative margins (17% vs 5.9%; OR: 2.89; p<0.001), and in patients with a Gleason score of 8-10 compared with those with a Gleason score of 2-6 (17% vs 4.2%; OR: 3.50; p<0.001). Limitations include lack of postprostatectomy prostate-specific antigen level. CONCLUSIONS Postoperative RT use for localized PCa in patients with adverse pathologic features is declining in the United States. PATIENT SUMMARY In this report, we show that use of postoperative radiotherapy in patients with prostate cancer with adverse pathologic features is declining. Patients treated at community cancer programs, those with locally advanced disease and positive margins, and those with a high Gleason score were more likely to receive postoperative radiotherapy.
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Affiliation(s)
| | - Phillip J Gray
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ahmedin Jemal
- American Cancer Society, 250 Williams Street NW, Atlanta, GA, USA
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Lobo JM, Dicker AP, Buerki C, Daviconi E, Karnes RJ, Jenkins RB, Patel N, Den RB, Showalter TN. Evaluating the clinical impact of a genomic classifier in prostate cancer using individualized decision analysis. PLoS One 2015; 10:e0116866. [PMID: 25837660 PMCID: PMC4383561 DOI: 10.1371/journal.pone.0116866] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/15/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Currently there is controversy surrounding the optimal way to treat patients with prostate cancer in the post-prostatectomy setting. Adjuvant therapies carry possible benefits of improved curative results, but there is uncertainty in which patients should receive adjuvant therapy. There are concerns about giving toxicity to a whole population for the benefit of only a subset. We hypothesized that making post-prostatectomy treatment decisions using genomics-based risk prediction estimates would improve cancer and quality of life outcomes. METHODS We developed a state-transition model to simulate outcomes over a 10 year horizon for a cohort of post-prostatectomy patients. Outcomes included cancer progression rates at 5 and 10 years, overall survival, and quality-adjusted survival with reductions for treatment, side effects, and cancer stage. We compared outcomes using population-level versus individual-level risk of cancer progression, and for genomics-based care versus usual care treatment recommendations. RESULTS Cancer progression outcomes, expected life-years (LYs), and expected quality-adjusted life-years (QALYs) were significantly different when individual genomics-based cancer progression risk estimates were used in place of population-level risk estimates. Use of the genomic classifier to guide treatment decisions provided small, but statistically significant, improvements in model outcomes. We observed an additional 0.03 LYs and 0.07 QALYs, a 12% relative increase in the 5-year recurrence-free survival probability, and a 4% relative reduction in the 5-year probability of metastatic disease or death. CONCLUSIONS The use of genomics-based risk prediction to guide treatment decisions may improve outcomes for prostate cancer patients. This study offers a framework for individualized decision analysis, and can be extended to incorporate a wide range of personal attributes to enable delivery of patient-centered tools for informed decision-making.
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Affiliation(s)
- Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
- * E-mail:
| | - Adam P. Dicker
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States of America
| | | | - Elai Daviconi
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - R. Jeffrey Karnes
- Department of Urology, Mayo Clinic, Rochester, MN, United States of America
| | - Robert B. Jenkins
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Nirav Patel
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Robert B. Den
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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