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UROLOGICAL
ONCOLOGY
Pathological
Outcomes and Biochemical Progression in Men with T1c Prostate Cancer Undergoing
Radical Prostatectomy with Prostate Specific Antigen 2.6 to 4.0 vs 4.1
to 6.0 ng/ml
Makarov DV, Humphreys EB, Mangold LA, Walsh PC, Partin AW, Epstein JI,
Freedland SJ
James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions,
Baltimore, Maryland, USA
J Urol. 2006; 176: 554-8
- Purpose:
Recent studies have suggested that the cut point for recommending prostate
biopsy among men with a normal digital rectal examination should be
greater than 2.5 ng/ml as opposed to the more traditional greater than
4.0 ng/ml. We compared outcomes between men with clinical stage T1c
disease undergoing radical prostatectomy who had a low vs slightly increased
prostate specific antigen.
- Materials
and Methods: The study population consisted of 2,896 men treated
with radical prostatectomy between 1985 and 2004 at a tertiary care
referral center with clinical stage T1c disease and a pre-biopsy prostate
specific antigen between 2.6 and 6.0 ng/ml. Using multivariate analysis
we evaluated the association between pre-biopsy prostate specific antigen
2.6 to 4.0 ng/ml (784) vs 4.1 to 6.0 ng/ml (2,112), and pathological
outcomes and biochemical progression.
- Results:
After adjusting for multiple clinical and pathological characteristics,
lower preoperative serum prostate specific antigen values were associated
with decreased odds of Gleason score 7 or greater in the surgical specimen
(p = 0.004), positive surgical margins (p = 0.02) and extraprostatic
extension (p = 0.001). There was no significant association between
these preoperative prostate specific antigen groups and odds of seminal
vesicle invasion (p = 0.47) or lymph node metastasis (p = 0.90). Among
the 1,534 men with followup information available there was a trend
for increased risk of biochemical progression associated with a higher
preoperative prostate specific antigen, although this trend did not
reach statistical significance (relative risk 1.48, 95% CI 0.69-3.19,
p = 0.31).
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Conclusions:
In the current study of men with clinical stage T1c treated with radical
prostatectomy a lower preoperative prostate specific antigen was associated
with significantly more favorable pathological findings. Whether this
degree of improved outcomes justifies the limitations associated with
decreasing the prostate specific antigen cut point (e.g. increased biopsies
performed and diagnosis of insignificant cancers) remains to be determined.
- Editorial
Comment
The authors focus on a rather large series of patients with a low serum
PSA and biopsy-confirmed prostate cancer undergoing radical prostatectomy.
Indeed, 784 patients with a PSA between 2.6 and 4.0 ng/mL were compared
to patients with a PSA between 4.1 and 6.0 ng/mL. I wonder how suspicion
of prostate cancer was generated in the first group, e.g. by abnormal
digital examination?
Nevertheless, the results are interesting and give support to the notion
that prostate cancer is an aggressive disease, even with low PSA. Positive
surgical margins and capsular penetration were found in 6% and 14%,
respectively, in the first group and in 9% and 21% in the higher PSA
group. Recurrence-free survival was inferior after 10 years in the elevated
PSA group.
What does that mean for the practicing urologist? To my opinion: detect
and treat prostate cancer as early as possible.
Dr.
Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany |