Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, CA; University of California San Francisco - Helen Diller Family Comprehensive Cancer Center San Francisco, CA.
Department of Urology, University of California, San Francisco, CA.
Urol Oncol. 2020 Oct;38(10):793.e1-793.e11. doi: 10.1016/j.urolonc.2020.07.012. Epub 2020 Aug 8.
New data is emerging to guide initial treatment of patients with metastatic prostate cancer (CaP). This study utilizes the Cancer of the Prostate Strategic Urologic Research Endeavor registry to evaluate variations in survival based on initial treatment received by men with metastatic disease at diagnosis or after progression.
Cancer of the Prostate Strategic Urologic Research Endeavor is a national registry of men diagnosed with CaP and managed at 43 community, academic, and Veteran's centers. We examined socio-demographic factors, disease biology, initial and subsequent therapy received, and survival among patients who presented with de novo or recurrent metastatic disease stratified by receipt of initial local therapy vs. combined local and hormonal therapy. The outcome was prostate cancer specific mortality (PCSM). We performed Fine and Gray competing risks regression analysis to evaluate the association between timing of metastasis and PCSM, adjusted for age, initial treatment, and subsequent therapy.
Of the 14,753 patients diagnosed with CaP from 1990 to 2016, 669 (5%) had metastatic disease. Among the examined patients, 303 (45%) had metastatic disease at diagnosis and 366 (55%) progressed to metastatic disease. Overall, 461 (69%) were ≥65 years old, 582 (87%) had Medicare, and 227 (34%) had an annual income < $30,000. Prostate-specific antigen at diagnosis was >20 ng/ml for 342 (51%) patients and biopsy Gleason grade was ≥4 + 3 for 386 (58%) patients. Among patients with metastatic disease at diagnosis, 31 (10%) received initial local therapy and 272 (90%) received initial hormonal therapy. Among patients who progressed to metastatic disease, 239 (65%) received initial local therapy and 127 (35%) received initial systemic hormonal therapy. Among patients with metastatic disease, the multivariate competing risks model, after adjusting for sociodemographics, marital status, diagnosis year, and comorbidities, revealed a significantly lower risk of PCSM among patients with de novo vs. recurrent metastatic disease (Hazard Ratio 0.66 (95% Confidence Interval 0.51, 0.85) P = 0.002). In the stratified analysis, no difference was seen for patients treated with initial hormonal vs. combined local and hormonal therapy.
In this analysis of a nationwide cohort of men treated for CaP with all types of therapy over 25 years, we observed that among men with metastatic CaP, the risk of PCSM was lower for de novo vs. recurrent metastatic disease. Additionally, no difference was observed based on initial treatment with combined local and hormonal therapy vs. hormonal therapy alone.
新数据的出现为转移性前列腺癌（CaP）患者的初始治疗提供了指导。本研究利用前列腺癌战略泌尿外科研究努力登记处，评估了在诊断时或进展后接受转移性疾病初始治疗的男性的生存变化，这些治疗包括初始治疗和后续治疗。
前列腺癌战略泌尿外科研究努力是一个全国性的登记处，登记了在 43 个社区、学术和退伍军人中心接受治疗的被诊断患有 CaP 的男性。我们检查了社会人口统计学因素、疾病生物学、接受的初始和后续治疗以及新诊断或复发转移性疾病患者的生存情况，这些患者按接受初始局部治疗与联合局部和激素治疗进行分层。结局是前列腺癌特异性死亡率（PCSM）。我们进行 Fine 和 Gray 竞争风险回归分析，以评估转移时间与 PCSM 之间的关联，调整因素包括年龄、初始治疗和后续治疗。
在 1990 年至 2016 年期间被诊断患有 CaP 的 14753 名患者中，有 669 名（5%）患有转移性疾病。在被检查的患者中，303 名（45%）在诊断时患有转移性疾病，366 名（55%）进展为转移性疾病。总体而言，461 名（69%）患者年龄≥65 岁，582 名（87%）有医疗保险，227 名（34%）年收入<30000 美元。342 名（51%）患者的前列腺特异性抗原在诊断时>20ng/ml，386 名（58%）患者的活检 Gleason 分级为≥4+3。在诊断时患有转移性疾病的患者中，31 名（10%）接受初始局部治疗，272 名（90%）接受初始激素治疗。在进展为转移性疾病的患者中，239 名（65%）接受初始局部治疗，127 名（35%）接受初始全身激素治疗。在患有转移性疾病的患者中，多变量竞争风险模型，在调整社会人口统计学、婚姻状况、诊断年份和合并症后，新发转移性疾病患者的 PCSM 风险显著低于复发性转移性疾病患者（风险比 0.66（95%置信区间 0.51，0.85）P=0.002）。在分层分析中，接受初始激素治疗与联合局部和激素治疗的患者之间没有差异。
在这项对过去 25 年期间接受各种治疗的患有 CaP 的男性进行的全国性队列研究中，我们观察到在患有转移性 CaP 的男性中，新发转移性疾病患者的 PCSM 风险低于复发性转移性疾病患者。此外，与单独接受激素治疗相比，联合局部和激素治疗的初始治疗并没有观察到差异。
