15-year outcomes after radical prostatectomy: a new predictive model

An article just published by a highly respected group of specialists in the Journal of Clinical Oncology adds emphasis to the problem faced by patients newly diagnosed with low- or intermediate-risk localized prostate cancer.

Stephenson et al. set out to develop a “new and improved” model for assessment of the  long-term risk of prostate cancer-specific mortality (PCSM) after radical prostatectomy appropriate  for patients diagnosed and treated in the current era of widespread PSA testing.

They analyzed data from 12,677 patients treated with radical prostatectomy between 1987 and 2005 at four tertiary care institutions (Baylor College of Medicine, the University of Michigan, Memorial Sloan-Kettering Cancer Center, and the Cleveland Clinic) and used clinical information and treatment outcome data to predict PCSM.

The results of their study showed that:

  • 15-year PCSM and all-cause (overall) mortality rates were 12 and 38 percent, respectively.
  • The estimated PCSM ranged from 5 to 38 percent for patients in the lowest and highest quartiles of predicted risk of PSA-defined recurrence, based on the widely used Kattan nomogram.
  • The biopsy-based Gleason score, PSA at time of surgery, and year of surgery were all specifically associated with PCSM.

The authors also developed what appears to be a relatively accurate nomogram capable of predicting the 15-year risk of PCSM. The inclusion of preoperative PSA velocity and body mass index did not improve the predictive accuracy of this nomogram, and application of the nomogram led to two further conclusions:

  • Only 4 percent of contemporary patients treated at one of these specialized, academic, tertiary care centers had a predicted 15-year PCSM of > 5 percent, despite the presence of apparently adverse clinical features.

However, the authors have been careful to point out that there are a lot of really important things that we still don’t know about the appropriateness of early intervention for treatment of localized prostate cancer:

  • This apparently favorable prognosis may be related to the effectiveness of radical prostatectomy (with or without secondary therapy) — but it could also just reflect the low lethality of prostate cancers detected in widespread PSA screening programs.
  • Our currently limited ability to identify contemporary patients at elevated risk of PCSM, there is a strong and evident need for new and better tests specifically associated with the biology of lethal types of prostate cancer.

This study also does not help us to resolve the issues related to the relative merits of active surveillance as compared to surgery as an initial treatment strategy, given the well understood risks for adverse events that are associated with surgery.

Quoted in a media release issued by the Memorial Sloan-Kettering Cancer Center earlier today, the senior author of the study, Dr. Peter Scardino, stated that, “The importance of this paper is that it shows a remarkably low risk of dying of prostate cancer within 15 years for treated men, and supports the concept that men with slow-growing cancers may not need immediate treatment.” He continued by saying, “Further good news is that surgery was very effective in preventing death in men with aggressive cancers — defined as those with a high PSA, poorly differentiated with a Gleason grade of 8-10, or locally extensive,”

The other important point that The “New” Prostate Cancer InfoLink would make is that these data are based on analysis of patients largely treated by highly specialized prostate cancer surgeons at highly specialized prostate cancer clinics in major academic centers. It may not be appropriate to assume that similar 15-year outcomes can be obtained by “average” community-based urologists. We have long pointed out for newly diagnosed patients that, if surgery (in particular) is your treatment of choice, then having the operation carried out by the most skilled specialist you can get to is a key aspect of optimizing the likelihood of a good outcome.

12 Responses

  1. Thank you for this. Pity that they want $22 to read the article.

  2. Is there any meaningful data out there beyond fifteen years? One of the frustrations of being diagnosed at 44 is that I’d have liked to know about 20, 30, and even 40-year outcomes.

  3. Kevin: There are 25-year data from Johns Hopkins based on Walsh’s patients going back to 1982. However, some have argued that this is a highly selected group of patients. The Johns Hopkins data would appear to be closely comparable to the data published in the current study. There is little doubt that surgery is a highly effective option for the treatment of prostate cancer — so long as you have a really good surgeon and you are not one of those patients who “gets unlucky” with long-term adverse effects. I am not aware of any good data giving outcomes to surgery for longer than 25 years.

  4. Kevin: I was 42 when diagnosed. I had surgery at Johns Hopkins by Partin for the exact reasons above. I am betting that in 15 years we will have another option for treatment. I read an article from Partin and he stated “prostate cancer is on thin ice and the ice is going to crack. ” I hope he is right. I have the article if you want it.

  5. By the way, the Johns Hopkins 15-year data had no deaths and only 5 recurrences among 2,526 low-risk patients.

  6. For some context, please take a look at the abstract of Dr. Albertson’s study of 20-year survival based on a competing risk analysis among men who were diagnosed with clinically localized prostate cancer and treated with observation or androgen withdrawal therapy alone, stratified by age at diagnosis and histological findings.

    “The prostate cancer mortality rate was 33 per 1000 person-years during the first 15 years of follow-up (95% confidence interval [CI], 28-38) and 18 per 1000 person years after 15 years of follow-up (95% CI, 10-29). The mortality rates for these 2 follow-up periods were not statistically different, after adjusting for differences in tumor histology (rate ratio, 1.1; 95% CI, 0.6-1.9). Men with low-grade prostate cancers have a minimal risk of dying from prostate cancer during 20 years of follow-up (Gleason score of 2-4, 6 deaths per 1000 person-years; 95% CI, 2-11). Men with high-grade prostate cancers have a high probability of dying from prostate cancer within 10 years of diagnosis (Gleason score of 8-10, 121 deaths per 1000 person-years; 95% CI, 90-156). Men with Gleason score of 5 or 6 tumors have an intermediate risk of prostate cancer death.”

  7. The issue of “How long have I got?” is rarely discussed in Forums or on Lists for some reason I have never been able to fathom.

    I recently wrote a piece which you can find on my Yananow web site to help men focus on the issues that might impact on survival. I had a positive response and a number of men said they found this useful.

  8. What’s the risk after radical prostatectomy with a positive margin at the bladder neck with a Gleason score of 6?

  9. Kinda depends on the size of the positive margin, but unless it was large my general tendency would be to think that this wasn’t that big of a deal.

  10. It was 3 mm at the bladder neck. Dx. was made from turp chips

  11. Assuming the same equipment, is radiation treatment for a positive margin after radical prostatectomy just as good at the community hospital as the university center?

  12. Robert:

    (1) That is a small positive margin. I think you would get different opinions from different specialists as to whether immediate adjuvant radiation was necessary. I don’t think anyone can tell you with certainty what is “right” or “wrong” in a case like this.

    (2) With respect to the quality of care issue, what is important is the skill and experience of the treatment team. Radiation to the bladder neck needs to be done with great accuracy to minimize side effects. If I was going to have such radiation therapy, I would want it done by a radiation therapy team that had done this many times before, using the most accurately targetable equipment available.

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