Beckmann Kerri R, O'Callaghan Michael E, Ruseckaite Rasa, Kinnear Ned, Miller Caroline, Evans Sue, Roder David M, Moretti Kim
Centre for Population Health Research, School of Health Science, University of South Australia, Adelaide, SA, Australia.
South Australian Prostate Cancer Clinical Outcomes Collaborative, Department of Urology, Repatriation General Hospital, Daw Park, SA, Australia.
BJU Int. 2017 Jun;119(6):862-871. doi: 10.1111/bju.13622. Epub 2016 Sep 3.
To compare clinical features, treatments and outcomes in men with non-metastatic prostate cancer (PCa) according to whether they were referred for symptoms or elevated prostate-specific antigen (PSA) level.
This study used data from the South Australia Prostate Cancer Clinical Outcomes Collaborative database; a multi-institutional clinical registry covering both the public and private sectors. We included all non-metastatic cases from 1998 to 2013 referred for urinary/prostatic symptoms or elevated PSA level. Multivariate Poisson regression was used to identify characteristics associated with symptomatic presentation and compare treatments according to reason for referral. Outcomes (i.e. overall survival, PCa-specific survival, metastasis-free survival and disease-free survival) were compared using multivariate Cox proportional hazards and competing risk regression.
Our analytical cohort consisted of 4 841 men with localized PCa. Symptomatic men had lower-risk disease (incidence ratio [IR] 0.70, 95% confidence interval [CI] 0.61-0.81 for high vs low risk), fewer radical prostatectomies (IR 0.64, CI: 0.56-0.75) and less radiotherapy (IR 0.86, CI: 0.77-0.96) than men presenting with elevated PSA level. All-cause mortality (hazard ratio [HR] 1.31, CI: 1.16-1.47), disease-specific mortality (HR 1.42, CI: 1.13-1.77) and risk of metastases (HR 1.36, CI: 1.13-1.64) were higher for men presenting with symptoms, after adjustment for other clinical characteristics; however, risk of disease progression did not differ (HR 0.90, CI: 0.74-1.07) amongst those treated curatively. Subgroup analyses indicated poorer PCa survival for symptomatic referral among men undergoing radical prostatectomy (HR 3.4, CI: 1.3-8.8), those aged >70 years (HR 1.4, CI: 1.0-1.8), men receiving private treatment (HR 2.1, CI: 1.3-3.3), those diagnosed via biopsy (HR 1.3, CI: 1.0-1.7) and those diagnosed before 2006 (HR 1.6, CI: 1.2-2.7).
Our results suggest that symptomatic presentation may be an independent negative prognostic indicator for PCa survival. More complete assessment of disease grade and extent, more definitive treatment and increased post-treatment monitoring among symptomatic cases may improve outcomes. Further research to determine any pathophysiological basis for poor outcomes in symptomatic men is warranted.
根据男性非转移性前列腺癌（PCa）是因症状就诊还是因前列腺特异性抗原（PSA）水平升高就诊，比较其临床特征、治疗方法及治疗结果。
本研究使用了南澳大利亚前列腺癌临床结果协作数据库的数据；该数据库是一个覆盖公共和私营部门的多机构临床登记系统。我们纳入了1998年至2013年所有因泌尿系统/前列腺症状或PSA水平升高而转诊的非转移性病例。采用多变量泊松回归分析确定与症状性表现相关的特征，并根据转诊原因比较治疗方法。使用多变量Cox比例风险回归和竞争风险回归比较治疗结果（即总生存、PCa特异性生存、无转移生存和无病生存）。
我们的分析队列包括4841例局限性PCa男性患者。与因PSA水平升高就诊的男性相比，有症状的男性疾病风险较低（高风险与低风险的发病率比[IR]为0.70，95%置信区间[CI]为0.61 - 0.81），接受根治性前列腺切除术的比例较低（IR为0.64，CI：0.56 - 0.75），接受放疗的比例较低（IR为0.86，CI：0.77 - 0.96）。在对其他临床特征进行调整后，有症状的男性全因死亡率（风险比[HR]为1.31，CI：1.16 - 1.47）、疾病特异性死亡率（HR为1.42，CI：1.13 - 1.77）和转移风险（HR为1.36，CI：1.13 - 1.64）较高；然而，接受根治性治疗的患者中疾病进展风险没有差异（HR为0.90，CI：0.74 - 1.07）。亚组分析表明，在接受根治性前列腺切除术的男性（HR为3.4，CI：1.3 - 8.8）、年龄>7岁（HR为1.4，CI：1.0 - 1.8）、接受私立治疗的男性（HR为2.1，CI：1.3 - 3.3）、通过活检确诊的男性（HR为1.3，CI：1.0 - 1.7）以及2006年前确诊的男性（HR为1.6，CI：1.2 - 2.7）中，因症状转诊的PCa生存率较低。
我们的结果表明，症状性表现可能是PCa生存的独立不良预后指标。对有症状病例进行更全面的疾病分级和范围评估、更明确的治疗以及增加治疗后监测可能会改善治疗结果。有必要进一步研究确定有症状男性预后不良的任何病理生理基础。
