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Clinical question
Does the rate of rise of prostate specific antigen predict the outcome
following radical prostatectomy for men with prostate cancer?
Bottom line
The rate of rise of prostate specific antigen is a strong independent
predictor of outcome following radical prostatectomy for men with stage 1 or
stage 2 prostate cancer. Specifically, a rise of more than 2.0 ng per
milliliter per year is associated with lymp node metastasis and higher grade
disease.This information may help guide follow-up and the use of adjuvant
treatments in future studies.
Level Of Evidence
1b
Reference
D'Amico AV, Chen M-H, Roehl KA, and Catalona WJ. Preoperative PSA velocity
and the risk of death from prostate cancer after radical prostatectomy. N
Engl J Med 2004; 351: 125-35.
Study design:
Cohort (prospective)
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
The prostate specific antigen (PSA) velocity is the rate of rise in PSA
levels, and has been associated with the stage and grade of prostate cancer
at the time of detection. In this study, 1804 men entered a prostate cancer
screening program, were given a diagnosis of prostate cancer, and were
treated with radical prostatectomy. Of this group, 1095 had a PSA test both
preoperatively and 1 year earlier and did not undergo adjuvant hormonal
therapy or radiotherapy. All men underwent radical prostatectomy. Most had
relatively low PSA values: 43% had a level of less than 4.0 ng/mL; 52% had a
level between 4 and 10 ng/mL. Most also had a low to moderate Gleason score
(84% scored <= 6), indicating a less aggressive tumor. All had stage 1c
(71%), 2a (24%), 2b (4%), or 2c (< 1%) disease. There is no mention of
whether pathologists were blinded to the PSA scores. The median duration of
follow-up was 5.1 years, and data were available for approximately 97% of
patients. As with previous studies, a PSA velocity of more than 2.0 ng per
milliliter per year was associated with lymph node metastasis, a more
advanced pathologic stage, and higher clinical grade disease. It was also
associated with a greater likelihood of recurrence (adjusted relative risk [ARR]
= 1.6; 95% confidence interval [CI], 1.1 - 1.9), a higher rate of death from
prostate cancer (ARR = 9.8; 95% CI, 2.8 - 34.3), and death from any cause (ARR
= 1.9; 95% CI, 1.2 - 3.2). Regarding the risk of death from prostate cancer,
this ARR (7.4) was similar to that for tumor stage 2 vs tumor stage 1c and
greater than that for Gleason score 8 to 10 vs Gleason score 2 to 6 (ARR =
3.4). Among the 833 men with a PSA velocity of less than or equal to 2.0 ng
per milliliter per year at diagnosis, only 3 died during the 5 years of
follow-up, compared with 24 of 262 with PSA velocity of more than 2.0 ng per
milliliter per year (0.4% vs 9.2%). |