A nomogram predicting prostate cancer-specific mortality after radical prostatectomy.

OBJECTIVE: We describe a model capable of predicting prostate cancer (PCa)-specific mortality up to 20 years after a radical prostatectomy (RP), which can adjust the predictions according to disease-free interval. PATIENTS AND METHODS: 752 patients were treated with RP for organ-confined PCa. Cox regression modeled the probability of PCa-specific mortality. The significance of the predictors was confirmed in competing risks analyses, which account for other-cause mortality. RESULTS: The mean follow-up was 11.4 years. The 5-, 10-, 15- and 20-year actuarial rates of PCa-specific survival were 99.0, 95.5, 90.9 and 85.7%, respectively. RP Gleason sum (p < 0.001), pT stage (p = 0.007), adjuvant radiotherapy (p = 0.03) and age at RP (p = 0.004) represented independent predictors of PCa-specific mortality in the Cox regression model as well as in competing risks regression. Those variables, along with lymph node dissection status (p = 0.4), constituted the nomogram predictors. After 200 bootstrap resamples, the nomogram achieved 82.6, 83.8, 75.0 and 76.3% accuracy in predicting PCa-specific mortality at 5, 10, 15 and 20 years post-RP, respectively. CONCLUSIONS: At 20 years, roughly 20% of men treated with RP may succumb to PCa. The current nomogram helps to identify these individuals. Their follow-up or secondary therapies may be adjusted according to nomogram predictions.

Adjuvant radiotherapy after radical prostatectomy shows no ability to improve rates of overall and cancer-specific survival in a matched case-control study.

OBJECTIVE: To assess the effect of adjuvant radiotherapy (aRT) on the rate of cancer-specific and overall survival after radical prostatectomy (RP) in a group of patients with a long-term follow-up, as there is controversy about the benefit of aRT after RP for prostate cancer when endpoints beyond biochemical and local recurrence are considered. PATIENTS AND METHODS: Within a study cohort of 752 patients treated with RP, 118 (15.7%) received aRT; these patients were matched with controls who did not receive aRT after RP. Exact matches were made for pT stage, RP Gleason sum, surgical margin status, age (+/-10 years), year of surgery (+/-10 years) and delivery of hormonal therapy. Kaplan-Meier and life-table analyses were used to assess overall and cancer-specific survival RESULTS: The median (range) follow-up was 11.4 (0.1-41) years. The 10- and 20-year overall survival after RP in those with no aRT were, respectively, 81.1% and 44.8%, vs 75.5% and 40.0% in the aRT group (P = 0.1). The corresponding probabilities for cause-specific survival were, respectively, 97.3% and 89.0% vs 86.3% and 69.3% (P < 0.001). There was no statistically significant difference in the overall and cause-specific survival between the groups after matching (hazard ratio 0.9, log rank P = 0.6; and 2.1, log rank P = 0.1, respectively). CONCLUSIONS: Our analysis showed that, in a matched case-control study, aRT has no effect on overall and cancer-specific survival. Further randomized long-term studies are necessary to confirm these results.

A nomogram predicting metastatic progression after radical prostatectomy.

OBJECTIVES: To develop and internally validate a nomogram predicting the individual probability of metastatic progression after radical prostatectomy according to the length of disease-free interval. METHODS: Cox regression modeled the probability of metastatic progression of prostate cancer in 752 patients treated with radical prostatectomy with a mean follow up of 11.6 years (median 11.4; range 0.1-40.5). The significance of the predictors was confirmed in competing risks analysis, which accounts for other causes of mortality. The Cox regression model-based nomogram was internally validated with 200 bootstrap resamples. RESULTS: Eighty-five of 752 patients (11.3%) developed metastatic progression. The 5, 10, 15 and 20-year actuarial rates of metastatic progression-free survival were, respectively, 95.9, 90.5, 84.8 and 80.5%. Pathological stage T3, elevated radical prostatectomy Gleason sum and delivery of adjuvant radiotherapy represented independent predictors of metastatic progression in both Cox and competing risks regression models, and constituted the nomogram predictors along with a fourth variable describing the presence of co-morbidities. After 200 bootstrap resamples the nomogram achieved 80.2, 77.7, 77.6 and 76.0% accuracy in predicting metastatic progression at 5, 10, 15 and 20 years after radical prostatectomy. CONCLUSIONS: Metastatic progression is a sign of poor prognosis in men with prostate cancer. Our nomogram is able to accurately predict the conditional probability of metastatic progression up to 20 years after radical prostatectomy.

Comparing the costs of radiation therapy and radical prostatectomy for the initial treatment of early-stage prostate cancer.

PURPOSE: Radical prostatectomy and external-beam radiation are the most common treatments for localized prostate cancer. Given the absence of clinical consensus in favor of one treatment or the other, relative costs may be a significant factor. This study compares the direct medical costs during the month before and 9 months after diagnosis for patients treated primarily with external-beam radiation or radical prostatectomy for early-stage prostate cancer. METHODS: Patients age 65 or older and coded by the Surveillance, Epidemiology, and End Results (SEER) registry as having been diagnosed with adenocarcinoma of the prostate treated primarily with external-beam radiation or radical prostatectomy during 1992 and 1993 were identified. The initial treatment costs, as measured by Medicare-approved payment amounts, for each strategy were analyzed using linked SEER-Medicare claims data after adjusting for differences in comorbidity and age. An intent-to-treat analysis was also performed to adjust for differences in staging between the two groups. RESULTS: For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P <.001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P <.001). CONCLUSION: For patients with early-stage prostate cancer, average costs during the initial treatment interval were at least 23% greater for radical prostatectomy than for external-beam radiation. Major limitations of the research include not studying costs after the initial treatment interval and questionable current applicability, given changes in management of early prostate cancer.

A nomogram predicting long-term biochemical recurrence after radical prostatectomy.

BACKGROUND: Men who undergo radical prostatectomy (RP) are at long-term risk of biochemical recurrence (BCR). In this report, the authors have described a model capable of predicting BCR up to at least 15 years after RP that can adjust predictions according to the disease-free interval. METHODS: Cox regression was used to model the probability of BCR (a prostate-specific antigen level>0.1 ng/mL and rising) in 601 men who underwent RP with a median follow-up of 11.4 years. The statistical significance of nomogram predictors was confirmed with a competing-risks regression model. The model was validated internally with 200 bootstraps and externally at 5 years, 10 years, and 15 years in 2 independent cohorts of 2963 and 3178 contemporary RP patients from 2 institutions. RESULTS: The 5-year, 10-year, 15-year, and 20-year actuarial rates of BCR-free survival were 84.8%, 71.2%, 61.1%, and 58.6%, respectively. Pathologic stage, surgical margin status, pathologic Gleason sum, type of RP, and adjuvant radiotherapy represented independent predictors of BCR in both Cox and competing-risks regression models and constituted the nomogram predictor variables. In internal validation, the nomogram accuracy was 79.3%, 77.2%, 79.7%, and 80.6% at 5 years, 10 years, 15 years, and 20 years, respectively, after RP. In external validation, the nomogram was 77.4% accurate at 5 years in the first cohort and 77.9%, 79.4%, and 86.3% accurate at 5 years, 10 years, and 15 years, respectively, in the second cohort. CONCLUSIONS: Patients who undergo RP remain at risk of BCR beyond 10 years after RP. The nomogram described in this report distinguishes itself from other tools by its ability to accurately predict the conditional probability of BCR up to at least 15 years after surgery.

Prostate cancer-specific survival in men treated with hormonal therapy after failure of radical prostatectomy.

OBJECTIVES: We hypothesized that prostate cancer-specific survival (PCaSS) could be accurately predicted in men in whom radical prostatectomy (RP) failed and who received hormonal therapy (HT) after RP failure. METHODS: Between 1954 and 1994, 752 consecutive patients underwent RP without neoadjuvant therapy. Of those, 114 patients (15.2%) received HT at RP failure and represent the focus of this analysis. Cox regression models and a nomogram targeted PCaSS. The main predictor was timing of HT initiation: at prostate-specific antigen (PSA) versus local versus distant recurrence. Covariates included age at HT, pathologic T stage, surgical margin status and Gleason sum at RP, use of adjuvant or salvage radiation, and time from RP to HT. RESULTS: Mean and median follow-up periods were 5.1 and 3.9 yr; 70 deaths were recorded, of which 45 (39.8%) were due to PCa. At 1, 5, 10, and 15 yr, the estimates of PCaSS were, respectively, 97.1%, 68.3%, 49.3%, and 30.2% (median, 9.8 yr). Younger men and those with HT initiated at the time of distant recurrence had lower PCaSS. A nomogram predicting PCaSS at 2, 3, 4, and 5 yr after RP was developed and demonstrated 66% accuracy after 200-bootstrap internal validation. CONCLUSION: Despite RP failure, half the patients can expect to survive for 10 yr. The nomogram can help in discriminating between those with better versus worse PCaSS, better than relying on most educated guesses.

25-year prostate cancer control and survival outcomes: a 40-year radical prostatectomy single institution series.

PURPOSE: We report on 25-year cancer control and survival outcomes after radical prostatectomy in a single center series of patients treated during a 40-year period. MATERIALS AND METHODS: Between 1954 and 1994, 787 consecutive patients underwent radical prostatectomy at Virginia Mason Medical Center in Seattle, Washington. Kaplan-Meier 25-year probabilities of prostate cancer specific, overall, prostate specific antigen progression-free, local and distant progression-free survival were determined. Multivariate Cox regression models addressed prostate cancer specific mortality. RESULTS: Prostate cancer specific survival, overall survival, prostate specific antigen progression-free survival, local and distant progression-free survival ranged from 99.0% to 81.5%, 93.5% to 19.3%, 84.8% to 54.5%, 95.3% to 87.8% and 95.9% to 78.2%, respectively. In univariate analyses pathological stage, surgical margin status, pathological Gleason sum, delivery of hormonal therapy and radiotherapy represented statistically significant predictors of prostate cancer specific mortality (all p < or =0.001). In multivariate analyses only Gleason sum (p = 0.03) and delivery of hormonal therapy (p < 0.001) remained significant. CONCLUSIONS: This is one of the most mature radical prostatectomy series. It demonstrates that long-term biochemical cancer control outcomes after radical prostatectomy might be suboptimal. However, local and distant control outcomes are excellent, and cancer specific mortality is minimal even 25 years after surgery.