Local, distant prostate cancer control strong after prostatectomy

Seattle-Radical prostatectomy provides effective local and distant disease control and is associated with minimal long-term disease-specific mortality, according to results from a retrospective review analyzing 30-year outcomes.

In Kaplan-Meier survival analysis, the median prostate cancer-specific survival had not yet been reached, while the mean prostate cancer-specific survival was 34.6 years.

"There have been only three other published studies of outcomes after radical prostatectomy featuring follow-up exceeding 20 years, and our series is more mature than any of those. While our results indicate biochemical risk may be suboptimal, with 35% of men at risk for biochemical recurrence at 20 years, about 76% of men remained free of metastasis and prostate cancer-specific mortality 30 years after their surgery," added Dr. Lewinshtein, who presented the findings at the 2010 AUA annual meeting in San Francisco.

About half of the patients were operated on before the beginning of the PSA era, and only 12% had T1c disease, while almost 60% had a PSA in the range of 4.0 to 10.0 ng/mL at the time of surgery. About half of the patients underwent perineal radical prostatectomy.

Pathologic Gleason sum scores were based on the original grading performed after surgery. About 35% of men had a Gleason sum of 7 or higher, 44% had extracapsular extension, and 40% had positive margin status.

Only 5% of men had radiotherapy, and 16% received androgen deprivation therapy.

The investigators acknowledged that the clinical characteristics of this population differ in several respects from a contemporary population of men undergoing radical prostatectomy for prostate cancer. On that basis, they speculated that prostate cancer-specific survival would likely be more favorable in a current series.

"Unfortunately, we can't have our cake and eat it too," said Dr. Porter, co-director of urologic oncology, clinical research, and director of the urologic oncology fellowship at Virginia Mason. "We can't have data that both provides long-term outcomes and is from a contemporary series."

The data were also analyzed to identify predictors of prostate cancer-specific mortality. In univariate analysis, preoperative PSA >19.9 ng/mL, pathologic Gleason sum 8-10, positive margin status, pathologic stage T3, biochemical recurrence, and distant recurrence were significant predictors of prostate cancer-specific mortality.

In logistic regression multivariate analysis, only preoperative PSA, biochemical recurrence, and distant recurrence retained prognostic value.

Dr. Lewinshtein noted that since about half the patients were operated on in the PSA era, the model was also run omitting PSA. In the latter analysis, pathologic Gleason sum became a strong, independent predictor of mortality.

"We are also regrading the Gleason scores using the contemporary criteria, considering there may be some undergrading in patients operated on earlier in the series prior to the revision of the Gleason system, and we will then re-analyze the data to see if Gleason score becomes an independent predictor of outcomes," he added.