Prostate Ca: PSA drop, active surveillance are key themes

Robert Abouassaly, MD, MScFusion biopsy, salvage versus adjuvant radiation therapy, and superextended versus extended pelvic lymph node dissection are also covered in the take home messages on prostate cancer from the 2016 AUA annual meeting. The prostate cancer take homes were presented by Robert Abouassaly, MD, MSc, of University Hospitals Case Medical Center, Cleveland.    

The effect of the United States Preventive Services Task Force's grade "D" recommendation against PSA-based screening for prostate cancer has been a decrease in screening since 2012 independent of race or insurance status, a decrease in referrals for an elevated serum PSA level, higher PSA levels at the time of referral, fewer prostate biopsies but more positive prostate biopsies, and a higher proportion of cancers with Gleason score greater-than-or-equal-to 8 and metastatic disease. Other series describe fewer prostatectomies performed, and of those being performed, there is a greater proportion being performed for Gleason score greater-than-or-equal-to 8 cancer as well as pathologic T3 disease and extraprostatic extension.

An evaluation of data from the European Randomised Study of Screening for Prostate Cancer found that 81% to 89% of the changes in prostate cancer mortality could be explained by a stage shift (cancers being detected at an earlier stage) rather than differences in treatment.

The risk of developing clinically significant prostate cancer with a baseline PSA <2 ng/mL at age 55 to 60 years is low at 5- and 13-year follow-up.

Use of the Prostate Health Index and multiparametric magnetic resonance imaging (MRI) in combination has better diagnostic performance than either alone in detecting clinically significant prostate cancer.

A multicenter validation study of a molecular urine test revealed that the HOXC6-DLX1 score model improved the accuracy of the detection of clinically significant prostate cancer over serum PSA alone.

Continue to the next page for more take home messages.

• A comparison of MRI-ultrasound (US) fusion biopsy to cognitive registration and traditional sextant biopsy found that the fusion technology improved the biopsy detection rate and pathologic grading.

• A randomized trial comparing MRI-transrectal ultrasound-guided fusion biopsy to standard biopsy found an improvement in the detection of clinically significant prostate cancer with fusion technology, and if the MRI was negative, only insignificant prostate cancers were missed.

• In a cost analysis model, cost was 25% less in a hypothetical cohort of 100 men with PSA elevation who undergo prostate MRI with MRI-US fusion biopsy, if indicated, compared with an initial TRUS-guided biopsy.

• A follow-up study (2006-2013) of an analysis of complications after TRUS-guided biopsy found that the hospitalization rate has remained stable at 4.1% and the overall mortality rate of 0.08% did not change throughout the study. The number of TRUS biopsies performed fell abruptly by 30.6% in 2013.

• A pre-biopsy checklist found that infection-related hospitalization rate was 0.70% and the most common risk factor associated with infection-related hospitalization following prostate biopsy was prior antibiotic use (31.8%).

• A higher biochemical cancer recurrence rate was found with delayed versus immediate radical prostatectomy (RP) in active surveillance-eligible patients who required RP.

• Patients with low-risk prostate cancer who enter AS have higher grade disease at RP but similar pathologic outcomes to those who undergo initial RP.

Next: Adjuvant versus salvage radiation therapy

• A higher rate of biochemical recurrence and a shorter time to biochemical recurrence were observed for patients on AS who progressed to RP compared with those who had immediate RP.

• Predominant Gleason pattern 4 was more common at the time of delayed RP in men on AS, but without a difference in biochemical recurrence, compared with immediate RP.

• A multi-institutional analysis of patients with T3N0 prostate cancer revealed no difference in 10-year metastasis-free survival between adjuvant and salvage radiation therapy.

• Post-prostatectomy radiation can be avoided in men with low clinical genomic risk.

• Adjuvant radiation shows an incremental cost of $17,206 and is associated with fewer quality-adjusted life-years compared with salvage radiation (3.7 vs. 4.4 years).

• Ninety-six percent of patients with positive lymph nodes were correctly staged with extended pelvic lymph node dissection.

• Superextended pelvic lymph node dissection may have a detrimental effect on functional outcomes (ie, continence and erectile function) compared with extended pelvic lymph node dissection.

• Superextended pelvic lymph node dissection increased the rate of overall complications, lymphedema, and lymphoceles compared with extended pelvic lymph node dissection.

Next: ADT, open versus robotic salvage RP

• In locally advanced non-metastatic prostate cancer, conservative therapy (androgen deprivation therapy) was associated with worse survival compared with surgery.

• A large multi-institutional database of 10,136 patients treated with RP and extended pelvic lymph node dissection from 1987 to 2014 showed the following trends: an increase in the rate of RP in high-grade disease, improved positive surgical margin rates, improved biochemical recurrence rates, and improved cancer-specific survival.

• Patients with very high-risk prostate cancer compared with high-risk prostate cancer had more extraprostatic extension, more seminal vesicle invasion, and a higher rate of biochemical recurrence and metastases at 5 years. Of those who had RP for very high-risk prostate cancer, with 18.6 months of follow-up, 47% had persistent or recurrent PSA and 15% developed metastases. The authors suggested that about one-third of patients may have been cured with surgery alone.

• There was no difference in health-related quality of life between RP and the combination of radiation therapy and androgen deprivation therapy in men with high-risk prostate cancer.

• Of 202 men with biochemical recurrence after RP with positive mpMRI and/or choline positron emission tomography, 33% exhibited local-only recurrence and 45% had metastatic-only relapses.

• A comparison of open versus robotic salvage RP found that the robotic approach had lower lymph node yield with lower blood loss, a lower anastomotic stricture rate, less rectal injury, and similar functional outcomes.

• In patients who underwent RP and had positive lymph nodes, adding ADT to external beam radiation improved cancer-specific survival and overall survival.

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