Survival After Robotic-assisted Prostatectomy for Localized Prostate Cancer: An Epidemiologic Study.

BACKGROUNDS: To determine the potential survival benefit associated with robotic-assisted laparoscopic prostatectomy (RALP) compared to open radical prostatectomy (ORP) for prostate cancer. SUMMARY OF BACKGROUND DATA: RALP has become the dominant surgical approach for localized disease in the absence of randomized clinical evidence and despite of the factor that RALP is more expensive than ORP. METHODS: We performed a cohort study involving patients who underwent RALP and ORP for localized prostate cancer at the Commission on Cancer- accredited hospitals in the United States. Overall survival was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards models, and propensity score-matched analyses. An interrupted time-series analysis using the surveillance, epidemiology, and end results program database was also performed. RESULTS: From 2010 to 2011, 37,645 patients received RALP and 12,655 patients received ORP. At a median follow-up of 60.7 months, RALP was associated with improved overall survival by both univariate [hazard ratio (HR), 0.69; P < 0.001] and multivariate analysis (HR, 0.76; P < 0.001) compared with ORP. Propensity score-matched analysis demonstrated improved 5-year all-cause mortality (3.9% vs 5.5%, HR, 0.73; P < 0.001) for RALP. The interrupted time-series analysis demonstrated the adoption of robotic surgery coincided with a systematic improvement in the 5-year cancer-specific survival rate of 0.17% (95% confidence interval, 0.06-0.25) per year after 2003 (P = 0.004 for change of trend), as compared to the time before adoption of RALP (1998-2003, annual percentage change, 0.01%; 95% confidence interval, -0.06 to 0.08). Sensitivity analysis suggested that the results from the interrupted time-series analysis were consistent with the improvement in the all-cause mortality demonstrated in the survival analysis (P = 0.87). CONCLUSIONS: In this epidemiologic analysis, RALP was associated with a small but statistically significant improvement in 5-year all-cause mortality compared to ORP for localized prostate cancer. This is the first time in the literature to report a survival benefit with RALP. Our findings have significant quality and cost implications, and provide assurance regarding a dominant adoption of more expensive technology in the absence of randomized controlled trials.

Comparative analysis of 1152 African-American and European-American men with prostate cancer identifies distinct genomic and immunological differences.

Racial disparities in prostate cancer have not been well characterized on a genomic level. Here we show the results of a multi-institutional retrospective analysis of 1,152 patients (596 African-American men (AAM) and 556 European-American men (EAM)) who underwent radical prostatectomy. Comparative analyses between the race groups were conducted at the clinical, genomic, pathway, molecular subtype, and prognostic levels. The EAM group had increased ERG (P < 0.001) and ETS (P = 0.02) expression, decreased SPINK1 expression (P < 0.001), and basal-like (P < 0.001) molecular subtypes. After adjusting for confounders, the AAM group was associated with higher expression of CRYBB2, GSTM3, and inflammation genes (IL33, IFNG, CCL4, CD3, ICOSLG), and lower expression of mismatch repair genes (MSH2, MSH6) (p < 0.001 for all). At the pathway level, the AAM group had higher expression of genes sets related to the immune response, apoptosis, hypoxia, and reactive oxygen species. EAM group was associated with higher levels of fatty acid metabolism, DNA repair, and WNT/beta-catenin signaling. Based on cell lines data, AAM were predicted to have higher potential response to DNA damage. In conclusion, biological characteristics of prostate tumor were substantially different in AAM when compared to EAM.

Improving risk stratification in a community-based African American population using cell cycle progression score.

BACKGROUND: Current clinical nomograms such as American Urological Association/National Comprehensive Cancer Network (AUA/NCCN) risk categories or CAPRA may not always reflect prostate cancer (PCa) risk among African American men. We evaluated the usefulness of adding a commercially available cell cycle progression (CCP) score to improve risk stratification in a community-based African American population. METHODS: Biopsy tissues from 150 African American and 60 Caucasian men were obtained from a single community urologic oncology practice in Memphis, TN. The biopsy samples were evaluated with a commercially available CCP panel (Prolaris). Clinical variables such as Gleason score, prostate-specific antigen (PSA), age, clinical stage, and extent of disease were combined to determine a single category of low-, intermediate-, or high-risk. AUA risk stratification for cancer aggressiveness was then compared between the CCP score vs. the clinical parameters to determine potential risk improvement by the CCP score. RESULTS: Based on the clinical parameters, of the 150 African American men evaluated, 20% were classified as low-risk, 40% were classified as intermediate-risk, and 40% were classified as high-risk. Of the 60 Caucasian men evaluated, 42% were low-risk, 42% were intermediate-risk, and 17% were high-risk. However, when re-evaluating the African American patients using the CCP score, 30% of the patients were determined to be more aggressive than the clinical low-risk category. Similarly, 21.67% of the patients were found to be more aggressive than the clinical intermediate-risk category, and 23.33% of the patients were more aggressive than the high-risk category. When compared to our Caucasian cohort, 12% of the low-risk patients, 8% of the intermediate-risk patients, and 10% of the high-risk patients were found to be more aggressive by the CCP score. Overall, 24% of African American men vs. 10% of Caucasian men were reclassified to a higher risk by CCP score. When we compared the mean CCP score in the African American population vs. the Caucasian population, the mean CCP score in the AUA low-risk was 3.2 vs. 2.9; 3.4 vs. 3.2 in the AUA intermediate-risk; and 3.8 vs. 3.5 in the AUA high-risk category, respectively. Despite the higher mean CCP score in the African American population, the difference between the African American men and the Caucasian men was not significant (P=0.064 for low-risk, P=0.204 for intermediate-risk, and P=0.209 for high-risk). CONCLUSIONS: Our data extends the evidence that CCP score derived from a biopsy specimen can be clinically useful. Our findings showed that the CCP score could stratify 10-year mortality risk in African American men beyond the current clinicopathologic features, which may better prepare patients for follow-up visits and discussions with their health care provider(s) and enhance their ability to select the most appropriate treatment option.