Death risk is low if prostate cancer hasn't progressed in 10 years

San Francisco-Most biochemical recurrence of prostate cancer following radical prostatectomy occurs within 10 years, and patients who remain free from progression a decade postoperatively can be counseled that their risk of subsequent cancer-related morbidity and mortality is low, say researchers from Johns Hopkins University, Baltimore.

"Little is known about the long-term natural history of PSA recurrence following radical prostatectomy in men who after 10 years have an undetectable PSA," said senior author Patrick C. Walsh, MD, professor of urology at the Johns Hopkins Brady Urological Institute. "Many patients believe that if their PSA is still undetectable at 10 years, then it will never go up. Fortunately, we've followed a large group of patients as long as 28 years and can help answer those questions."

"For urologists, that's valuable information in counseling patients who have their 10-year milestone and ask, 'What is my future risk of having a problem?'," Dr. Walsh told Urology Times.

Metastasis- and cancer-free estimates

In addition to looking for the rate and predictors of biochemical recurrence, Dr. Walsh's team also calculated actuarial metastasis-free and cancer-specific survival estimates at 20 years after prostatectomy.

Generally speaking, they found that higher clinical and pathologic stage was significantly associated with eventual recurrence on multivariable analysis. For men with organ-confined Gleason 6 tumors, the probability of biochemical recurrence was 3.9%. For those with a Gleason score of 3+4, the rate jumped to 12.3%, while for those with Gleason ≥4+3, it was 14.1%. When the tumors were extracapsular, probability of recurrence was calculated to be 17.8%, 8.4%, and 25.7%, respectively.

For those with positive surgical margins, probability is 29.4%, 20.5%, and 32.1%.

For patients with seminal vesicle invasion, recurrence is estimated to occur in 16.7% of Gleason 6 cases and 46.7% of Gleason ≥4+3 cases. (There were no patients with a Gleason score of 3+4 who had seminal vesicle disease.)

Among the 1.1% of men in the cohort with lymph node metastases, two-thirds (66.7%) with Gleason 6 can expect biochemical recurrence.

Probability of metastases was highest in patients with positive margins (7.9% for Gleason 3+4, 32.2% for Gleason ≥4+3) and those with seminal vesicle invasion (10% for Gleason 3+4, 20% for Gleason ≥4+3).

"We did not come in with any preconceived notions. These numbers should be viewed positively," Dr. Walsh.

Dr. Walsh cited previous research showing that biochemical recurrence most frequently occurs within 5 years of radical prostatectomy (J Urol 2000; 164:101-5; JAMA 1999; 281:1591-7).

Men in the study had a mean age of 58.3 years. Their median preoperative PSA was 5.6 ng/mL. A little over half (55%) had a clinical stage of T2 or higher, and a full 86% had Gleason scores <7.

Other authors from the Brady Urological Institute who contributed to the study are Stacy Loeb, MD, Ashley Ross, MD, PhD, Zhaoyong Feng, PhD, Mohamad E. Allaf, MD, and Bruce J. Trock, PhD.