Cancer control

Prostate cancer survival after radical prostatectomy is defined in a variety of ways, each of which deserves explanation. Common terms used include overall survival, cancer-specific survival, PSA non-progression and long-term progression-free probability. Because prostate cancer grows at such a slow rate with prolonged doubling times, use of overall survival as a clinical end-point in clinical trials is cumbersome and expensive. Thus several other end-points in prostate cancer research are used, including rate of PSA recurrence, rate of local or distant recurrence and cancer-specific survival.

PSA recurrence

Several studies have looked at the actuarial probability of PSA recurrence after radical prostatectomy over the past 30 years, with remarkable concordance. The risk of PSA recurrence after RRP is significantly impacted by preoperative predictive factors, the most important of which are the preoperative serum PSA, biopsy Gleason score and clinical stage.7 With PSA recurrence variably defined as serum PSA >0.2ng/dl to >0.6 ng/dl by different groups, as shown in Table 24.1, the 5- and 10-year PSA non-progression rate for clinically localized (T1-T2Nx) prostate cancer ranges from 77% to 80% and 54% to 75%, respectively.711 Risk factors most strongly predictive of PSA failure include clinical stage, the pathologic Gleason grade and the preoperative serum PSA. Adverse features on the final pathologic specimen are also predictive of PSA failure; these include extracapsular extension of disease, seminal vesicle or regional nodal involvement, and positive surgical margins.7 However, the strongest predictors of risk of progression on multivariate analysis of preoperative markers remains clinical stage, Gleason grade and preoperative serum PSA.7

Combining all of these predictive factors (PSA, biopsy Gleason score, clinical stage, etc.) into a cogent summary for the patient to make his decision on treatment is the goal of decision analysis research in prostate cancer. If there is a significant chance of extraprostatic disease, nodal involvement and, ultimately, PSA recurrence after RRP, the patient is better able to make an informed decision. He can tailor his treatment approach to his own personal concerns about the different treatment modalities, and their respective risks and possible complications. Thus, several nomograms have developed to provide this type of information to patients and assist in their decision-making process. The two most prominent are the Partin tables and the Kattan nomogram.

Partin etal., using the Hopkins database of RRP patients, examined preoperative serum PSA, clinical stage and biopsy Gleason score to predict the final pathologic stage after RRP. This series was first reported on over 700 patients from the

Table 24.1. PSA progression-free probability after radical retropubic prostatectomy. Adapted from Eastham and Scardino (2002).105

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