A recent report in Cancer again seems to suggest that men with prostate cancer treated by radical prostatectomy (RP) who have a long time to biochemical recurrence (BCR) or a long PSA doubling time after BCR may have no higher overall risk of death than men who have no BCR at all.
Choueiri et al. conducted a retrospective analysis of data from 3,071 men who were treated with radical prostatectomy (RP) over a 20-year period at Duke University (between 1988 and 2008) and for whom complete, long-term follow-up data were available.
The data from this study are reported as follows:
- After a median follow-up of 7.4 years from the time of RP, 546/3,071 men (17.8 percent) men had had a BCR and 454/3,071 men (14.8 percent) had died (of all causes).
- The median follow-up after PSA failure was 11.2 years.
- Time-dependent BCR was associated with a very small increase in risk of death from any cause (adjusted hazards ratio or AHR = 1.03).
- In men who experienced BCR, a PSA doubling time < 6 months was associated with a significantly increased risk of overall death (AHR = 1.55).
- In men who received radiotherapy after their BCR, the risk of death was significantly lower (AHR, 0.58).
- In men who received hormone therapy after their BCR, the risk of death was also significantly lower (AHR, 0.56).
The authors conclude that the occurrence of BCR was associated with an increased the risk of death from any cause in men undergoing RP for prostate cancer. They also note that this risk of death increased significantly as the time to BCR shortened, and that the addition of RT and/or HT in men with BCR significantly lowered this risk.
Now it is worth noting that the 3,000+ men in this study included many form the pre-PSA and early PSA eras (when it is reasonable to suspect that even men with localized disease were getting diagnosed with more advanced forms of prostate cancer than those diagnosed today). What we can not tell from this study is whether there is any distinction in the impact of BCR on mortality today than there might have been 15-20 years ago.
Data presented previously by the Johns Hopkins group has suggested that men who have a BCR with a PSA doubling time of 15+ months after RP are at minimal risk for evident prostate cancer metastasis or prostate cancer-specific death, whereas those with a PSA doubling time of 3 months or less are at very high risk. These data from Duke appear to be supportive of a similar risk level. The question that needs resolution now is therefore, in a man with a BCR post-surgery, how does when best manage the patient based on his age, his comorbidities, and his PSA doubling time. It would appear that there is probably a significant percentage of men who’s quality of overall life is likely to be poorly impacted by early homone therapy or early radiation, and for whom any such therapy should be delayed for as long as reasonably possible.
Filed under: Living with Prostate Cancer, Management, Treatment Tagged: | biochemical recurrence, mortality, PSA doubling time, radical prostatectomy
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Yikes!! I hate it when I fall into that “very high risk group,” but it seems to happen quite often these days.
I know it must be very difficult for someone to chose not to do something proactive with a rising PSA even with a long doubling time. It would be good to give these guys some good guidelines to help balance QOL vs disease progression.
Bill