Elsevier

Urology

Volume 70, Issue 5, November 2007, Pages 950-955
Urology

Adult urology
Improved Stage and Grade-Specific Progression-Free Survival Rates After Radical Prostatectomy in the PSA Era

https://doi.org/10.1016/j.urology.2007.06.1119Get rights and content

Objectives

Since the initiation of prostate-specific antigen (PSA) screening, the progression-free survival (PFS) rates after radical prostatectomy have markedly improved. However, few studies have evaluated whether PFS has improved for stage and grade-matched patients. Our objective was to examine differences in PFS after radical prostatectomy between the pre-PSA era (before 1992) and the PSA era, controlling for tumor stage and grade.

Methods

From 1983 to 2003, 3456 men underwent radical prostatectomy by one surgeon. The 10-year PFS rates were calculated for each era and stratified by pathologic tumor stage and grade. Kaplan-Meier curves were generated to show biochemical PFS over time.

Results

The proportion of patients with pathologically organ-confined disease increased from 64% to 69%, consistent with stage migration. The PFS rate in the PSA era was 87%, 63%, 58%, and 31% versus 71%, 63%, 47%, and 19% in the pre-PSA era for Stage pT2R0, pT3R0, pT2-T3R1, and pT3c/N1 disease, respectively. The PFS rate stratified by Gleason grade in the PSA era was 84%, 63%, and 37% versus 66%, 49%, and 32% in the pre-PSA era for Gleason grade less than 7, 7, and 8 to 10, respectively. The 10-year PFS rate for organ-confined disease improved from 70% in the pre-PSA era to 86% in the PSA era.

Conclusions

Patients treated with radical prostatectomy in the PSA era have improved survival outcomes when controlling for pathologic stage and grade. This is likely attributed to the earlier detection of cancer through PSA screening, better identification of patients amenable to curative therapy, and the effects of lead-time bias.

Section snippets

Patients

Anatomic radical prostatectomy with pelvic lymph node dissection was performed by one surgeon (W.J.C.) on 3456 consecutive men from 1983 to 2003, using a previously reported technique.12 The extent of pelvic lymphadenectomy was similar throughout the study period.12 Men were categorized into two groups stratified by the treatment era: the pre-PSA screening era (1983 to 1991) and the PSA screening era (1992 to 2003). The eras were defined because PSA was initially reported as a first-line

Clinical Characteristics

A total of 3456 men were treated with radical prostatectomy (Table 1). The mean patient age was 65 years in the pre-PSA era and 60 years in the PSA era. The median PSA level in the pre-PSA era was 7.4 ng/mL and was 5.7 ng/mL in the PSA era. The median follow-up of patients in the PSA era was 42 months compared with 139 months in the pre-PSA era (P <0.0001). Five-year follow-up data were available for 1635 patients (47%), and 10-year follow-up data were available for 587 patients (17%); 53

Comment

Prostate cancer management has evolved considerably during the past 25 years. The introduction of PSA testing in the late 1980s, and its widespread use in screening programs in the early 1990s, has resulted in the earlier detection of cancer in younger patients.16 Newer models to predict the pathologic stage from preoperative parameters have allowed improved identification of patients with localized disease.4 As a result of these changes, more patients are identified at a time when their

Conclusions

The changes in the management of prostate cancer during the past decade, including the initiation of PSA screening and better biopsy strategies and surgical techniques, have improved the PFS of patients currently undergoing treatment. Our studies have shown within each individual pathologic stage and grade, improved PFS in the PSA era. The success of a good screening program, including stage migration, a reduction in metastatic disease, and a reduction in mortality, has now been noted. The

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This study was supported in part by Beckman Coulter, Incorporated, Fullerton, California, and the Urological Research Foundation.

Beckman Coulter provided the PSA kits at cost to W. J. Catalona.

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