A paper currently “in press” in the Journal of Urology suggests that annual PSA testing “may be safely discontinued after 10 years for men with a prostatectomy Gleason score 6 or less and/or limited life expectancy.”
Loeb et al. conducted a retrospective analysis of data from 10,609 men who received a radical prostatectomy as primary treatment for prostate cancer between 1978 and 2009 at Johns Hopkins Medical Center. Of these 10,000+ patients, 1,684 (15.9 percent) had biochemical recurrence, which was defined as a PSA level of 0.2 ng/ml or greater, at some time following their surgery. A further 1,583 patients (14.9 percent) had an undetectable PSA level at 10 years after their surgery. (An “undetectable” PSA level is not defined in the paper but is assumed to imply a PSA level < 0.1 ng/ml.)
The authors were primarily interested in studying predictors of late biochemical recurrence (i.e., recurrences occurring > 10 years after surgery).
Here are the key findings:
- This was a cohort of relatively young, relatively low-risk, primarily white patients.
- The average (mean) age was 58.1 years (range, 33 to 81 years).
- Only 789 (7.5 percent) were African American.
- The average (median) preoperative PSA level was 5.7 ng/ml.
- Clinical stage was T1c or less in 6,618/10,609 (62.8 percent).
- Biopsy Gleason scores were 6 or less in 8,021/10,609 (76.0 percent).
- 6,696/10,609 (63.3 percent) had organ-confined disease at the time of surgery.
- Surgical indicators of non-organ-confined disease at time of surgery included
- 3,099 cases of extracapsular extension (29.3 percent of patients)
- 1,512 cases of positive surgical margins (14.3 percent)
- 449 cases of seminal vesicle invasion (4.2 percent)
- 333 cases of lymph node metastasis (3.2 percent) men.
- Among the 1,684 men who had a biochemical recurrence
- 77.0 percent recurred within 5 years
- 16.6 percent recurred between 5 and 10 years
- 4.9 percent recurred between 10 and 15 years
- 1.5 percent recurred after 15 years
- Late recurrence (after 10 years or more) was associated with
- More favorable pathological features
- A higher likelihood of metastasis-free survival
- A higher probability of prostate cancer-specific survival
- Among the 1,583 patients with an undetectable PSA level at 10 years after surgery
- 99 men (6.3 percent) recurred at some later point in time
- The actuarial probability of biochemical recurrence and metastasis at 20 years varied by stage and by grade.
- No metastases were observed in patients with pathological Gleason scores 6 or less.
- 1/1,583 patients (0.06 percent) died of prostate cancer within 20 years.
The authors conclude that, in this cohort of patients (all treated at a single, high-volume, academic medical center), men with an undetectable PSA level for 10 or more years after their surgery have a low risk of subsequent biochemical recurrence, with correspondingly lower rates of metastasis and death.
Loeb and her colleagues further recommend that:
- Men with an undetectable PSA at 10 years after their surgery should be counseled that their risk of subsequent prostate cancer-related morbidity and mortality is low.
- Annual PSA testing may be safely discontinued after 10 years for men with an undetectable PSA level and a pathological Gleason score of 6 or less and/or limited life expectancy.