Prostate CancerPersistent Prostate-Specific Antigen After Radical Prostatectomy and Its Impact on Oncologic Outcomes
Introduction
Radical prostatectomy (RP) can provide good long-term oncological outcomes in patients with localized and locally advanced prostate cancer (PCa) [1], [2], [3]. After RP, prostate-specific antigen (PSA) represents the cornerstone for follow-up of patients. The current European Association of Urology (EAU) PCa guidelines recommend first PSA measurement at 3 mo after RP [4].
However, PSA is expected to be undetectable within 6 wk following RP [5]. Moreover, several investigators focused on persistent PSA after RP and relied on the definition of PSA ≥0.1 ng/ml at 6 wk after RP [6], [7], [8], [9], [10], [11], [12], [13], [14], [15].
Some of them reported an association between persistent PSA after RP and biochemical recurrence (BCR) [11], [13], [15]. Moreover, Ploussard et al. [12] reported that approximately 75% of patients with persistent PSA develop BCR. However, studies investigating the relationship between persistent PSA (≥0.1 ng/ml) at 6 wk and development of metastasis and survival after RP are scant or focus only on subgroups such as pN1 disease or patients with salvage radiotherapy (SRT). Previously, Bianchi et al. [7] reported a higher risk for clinical recurrence and cancer-specific mortality for persistent PSA in RP patients with pN1 disease. In addition, Fossati et al. [6] reported that persistent PSA represents an independent predictor for metastasis. However, the study by Fossati et al. [6] focused only on patients with pN0 who received SRT. Therefore, the impact of persistent PSA on long-term oncologic outcomes and the effect of SRT in patients with persistent PSA following RP need to be clarified.
To address these limitations, we investigated the relationship between persistent PSA at 6 wk after RP and the long-term oncological outcomes, within a large high-volume center database. Specifically, we investigated the relationship between persistent PSA and metastasis-free survival (MFS), overall survival (OS), and cancer-specific survival (CSS). Subgroup analyses focused on patients with persistent PSA. In addition, we tested for risk factors to develop persistent PSA. Finally, the impact of SRT versus no RT on OS and CSS in patients with persistent PSA was studied.
Section snippets
Study population
After Institutional Review Board approval, patients that underwent RP (1992–2016), from a single-institutional high-volume center database (Martini-Klinik Prostate Cancer Center, Germany), were identified.
Patients were stratified according to persistent (PSA ≥0.1 ng/ml at 6 wk after RP) versus undetectable PSA (PSA <0.1 ng/ml).
RP was performed with the use of an open retropubic or robot-assisted approach, as previously described [16]. Moreover, neurovascular bundle preservation was performed with
Descriptive statistics
Of 11 604 identified patients, 8.8% (n = 1025) versus 91.2% (n = 10 579) harbored persistent or undetectable PSA, respectively (Table 1). Around 10% (n = 125) of patients with persistent PSA at 6 wk had an undetectable PSA in the subsequent PSA testing. The median follow-up was 61.8 versus 46.4 mo for patients with undetectable and persistent PSA. Patients with persistent PSA were older (median age: 64.6 vs 64.2 yr, p = 0.006), more frequently had pathologic GG5 (19.6% vs 2.5%, p < 0.001), more frequently
Discussion
PSA after RP represents the cornerstone in follow-up of patients with PCa. Specifically, early PSA values after RP could help to identify patients at risk for worse oncologic outcome. Moreover, early PSA after RP could help to identify patients who benefit from further treatment. However, few previous studies tested the impact of persistent PSA on long-term oncologic outcomes. To address this void, we investigated the relationship between persistent PSA at 6 wk and the long-term oncologic
Conclusion
Persistent PSA at 6 wk after RP represents a strong prognostic predictor for development of metastasis and death after RP. Therefore, early measurement of PSA can be useful in clinical practice to identify patients with high risk for worse oncologic outcome. Moreover, SRT was associated with improved OS and CSS in patients with persistent PSA. In those with persistent PSA and additional risk factors, such as pT3b, GG3–5, positive surgical margin, or pN1, SRT should be considered.
Author
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