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PSA increase after radical prostatectomy may not predict recurrence
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Among patients with prostate cancer who have undergone radical prostatectomy, increases in PSA may not be predictive of progression to metastatic disease in the patient’s lifetime, according to study findings.
These findings suggest that for some patients, salvage therapy based only on PSA recurrence may not be necessary.
Ruth Etzioni
“Previous studies have indicated that the interval from PSA recurrence to metastasis is quite long, with a median of more than 8 years, even in the absence of any treatment for the recurrence,” Ruth Etzioni, PhD, of the public health sciences division at Fred Hutchinson Cancer Research Center, said in a press release. “Given that the majority of prostate cancer patients are older, we expect that many would die of other causes before reaching the point of metastasis.”
Etzioni and colleagues evaluated data on 4,455 patients enrolled in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database, as well as a cohort of 441 patients seen at Johns Hopkins University for a PSA recurrence after radical prostatectomy. These patients were followed for progression to metastatic disease. Information on relative survival from US life tables and the SEER registry also was utilized to determine time to other-cause death.
Based on these three data sources, the researchers used simulation modeling to predict outcomes using a virtual patient population of 1 million individuals. The model was created by sampling patient age, log, Gleason score and stage from the CaPSURE cohort. They used competing risks simulation to calculate the lower bound on the likelihood of overdetection of recurrence, stratified by age, clinicopathologic characteristics, and time from radical prostatectomy to PSA recurrence.
The researchers defined overdetection of recurrence as diagnosis of disease recurrence based solely on PSA in a patient who, without treatment, would not progress to metastatic disease within his lifetime.
The researchers found that in the CaPSURE registry cohort, the cumulative incidence of PSA recurrence was 13.6% at 5 years and 19.9% at 10 years. Among patients in the SEER registry who had undergone radical prostatectomy, the risk of other-cause death was 60% lower than in the age-matched US population.
According to study results, at least 9.1% of patients with PSA recurrence <5 years after radical prostatectomy and at least 15.6% of patients with PSA recurrence 5 to 10 years after radical prostatectomy were overdetected. Similarly, among patients who were older than 70 years at diagnosis and recurred within 10 years of initial diagnosis, at least 31.4% were overdetected.
“Salvage therapy for prostate cancer patients includes radiation therapy, which has side effects such as bowel problems and urinary symptoms, and hormone therapy, which can cause hot flashes, fatigue, loss of libido, and in the long run, has been linked with osteoporosis, heart disease, and even diabetes,” Etzioni said in the release. “Our findings are in line with treatment studies showing that immediate salvage therapy following detection of rising PSA levels is not the right thing for everyone. We need to develop ways to determine who needs salvage therapy and when to give it.”
Disclosure: One researcher reports receiving a commercial research grant from Myriad Genetics and has provided expert testimony on diabetes treatment for Sonacare Medical, LLC.
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