Risk stratification of men with high-risk prostate cancer prior to first-line surgery


A new French study has attempted to provide a better appreciation of the effect of predictive factors on the biochemical recurrence-free and overall survival of patients with high-risk prostate cancer after a radical prostatectomy (RP).

Ploussard et al. re-analyzed data from 813 French patients with high-risk disease who received an RP as first-line treatment in a national, retrospective, multi-institutional study.

In this study, high-risk prostate cancer was defined by the presence of one or more of the following criteria at the time of diagnosis:

  • A PSA level of  20 ng/ml or higher
  • A Gleason score of 8 to 10
  • The presence of clinical stage T2cNxM0 to T4NxM0 disease.

Their analysis provides the following results:

  • The average median follow-up of the 813 patients was 64 months.
  • Organ-confined disease (pT2N0M0 disease) was reported in 36.5 percent of patients (297/813).
  • Survival rates at 5 years of follow-up were
    • Biochemical recurrence-free survival, 74.1 percent
    • Metastasis-free survival, 96.1 percent
    • Overall survival, 98.6 percent
  • Each of the three above-listed preoperative criteria of high-risk prostate cancer was an independent predictor of biochemical (PSA-based) progression.
  • By comparison with men with just one risk factor for high-risk disease
    • The risk of biochemical recurrence increased 1.5-fold for men with two preoperative criteria of high risk.
    • For risk of biochemical recurrence increased 2.8-fold for men with all three preoperative criteria of high risk.
  • The probability of biochemical recurrence-free survival (but not the probability of overall survival) was significantly affected by the preoperative risk score (P < 0.001).
  • The postoperative risk score was significantly predictive for biochemical recurrence-free survival (P < 0.001) and overall survival (P < 0.035).
  • The probability of biochemical (PSA-based) failure was significantly increased (2- to4.6-fold) by an increasing postoperative risk score .

Ploussard et al. claim that  their risk stratification system might help clinicians to better predict the clinical and biochemical outcomes of high-risk patients after surgery. However, without a closer comparison of this model to the data available from the Kattan nomogram predictions, it is difficult to know just how really valuable this risk stratification might really be. Others might suggest that all of these high-risk patients were clear candidates for immediate adjuvant external beam radiation therapy after first-line surgery.

4 Responses

  1. Related question: How is metastasis-free survival defined in these studies? It seems that early stages of metastases are impossible to detect.

  2. Wolfram:

    Metastasis-free survival usually means no evident metastasis on a bone scan or CT scan as appropriate. In other words, it is a reference to truly evident metastasis, not micrometastasis.

  3. I would be interested in the statistics at 10 years. Pardon me if I remain skeptical of the author’s conclusion of 75% “disease-free” at 5 years with just RP, and I would like to know the Gleason scores and numbers of those that were in that category. For that matter, it would be interesting to know the Gleason scores of the 25% not so fortunate.

  4. Chuck: The information you are seeking is likely available in the full text of the paper if you want to ask the authors for a copy.

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