Department of General, Oncological and Functional Urology, Medical University of Warsaw, Warsaw, Poland.
Department of Urology, APHM, North Academic Hospital, Marseille, France.
Prostate. 2023 Nov;83(15):1504-1515. doi: 10.1002/pros.24609. Epub 2023 Aug 7.
Patients with nonmetastatic prostate cancer (nmPCa) and high prostate-specific antigen (PSA) levels due to the high likelihood of metastasis pose a clinical dilemma regarding their optimal treatment and long-term outcomes after initial local therapy. We aimed to evaluate the oncologic outcomes of patients treated with radical prostatectomy (RP) or radiotherapy (RT) for nmPCa with high PSA levels.
We queried the Surveillance, Epidemiology, and End Results (SEER) database to identify patients diagnosed with nmPCa who received RP or RT from 2004 through 2015. We included nmPCa patients with high PSA levels categorized as ≥50 and ≥98 ng/mL, the highest level recorded in SEER. We used the Kaplan-Meier method and Cox proportional hazards to analyze cancer-specific (CSS) and overall survival (OS).
We included 6177 patients with nmPCa and PSA ≥ 50 ng/mL at diagnosis; 1698 (27%) had PSA ≥ 98 ng/mL. Of these, 1658 (26.8%) underwent RP and 4519 (73.16%) patients received primary RT. Within a median of 113 months (interquartile range 74-150 months), the 5- and 10-year CSS estimates were 92.3% and 81.5% respectively; 10-year OS was 61%. In the PSA ≥ 98 ng/mL subgroup 5- and 10-year CSS estimates were 89.2% and 76%, respectively. In multivariable analyses for CSS, ISUP grade group (p < 0.001), N stage (p < 0.001), treatment with RP (hazard ratio [HR] = 0.60, 95% confidence interval [CI] 0.43-0.83, p < 0.001), and patient's age (p < 0.05) were associated with improved CSS. In the whole cohort of patients with PSA ≥ 50 ng/mL and RP subgroup, PSA failed to retain its independent prognostic value for CSS.
Patients treated with local therapy for nmPCa with very high PSA at diagnosis have relatively good long-term oncological outcomes. Therefore, among well-selected patients with nmPCa, high PSA levels alone should not preclude the use of radical local therapy. Potential selection bias limits inferences about the relative effectiveness of specific local therapies in this setting.
由于转移的可能性很高，患有非转移性前列腺癌（nmPCa）和高前列腺特异性抗原（PSA）水平的患者在初始局部治疗后的最佳治疗和长期结果方面存在临床难题。我们旨在评估接受根治性前列腺切除术（RP）或放疗（RT）治疗 PSA 水平较高的 nmPCa 患者的肿瘤学结局。
我们在监测、流行病学和最终结果（SEER）数据库中查询了 2004 年至 2015 年期间接受 RP 或 RT 治疗的诊断为 nmPCa 且 PSA 水平高的患者。我们纳入了 PSA 水平≥50ng/ml 和≥98ng/ml 的 PSA 水平较高的 nmPCa 患者，PSA 水平是 SEER 中记录的最高水平。我们使用 Kaplan-Meier 方法和 Cox 比例风险分析来分析癌症特异性（CSS）和总体生存率（OS）。
我们纳入了 6177 名诊断为 PSA≥50ng/ml 的 nmPCa 患者；其中 1698 名（27%）PSA≥98ng/ml。其中，1658 名（26.8%）接受了 RP，4519 名（73.16%）患者接受了原发性 RT。在中位数为 113 个月（四分位距 74-150 个月）的随访中，5 年和 10 年 CSS 估计值分别为 92.3%和 81.5%；10 年 OS 为 61%。在 PSA≥98ng/ml 亚组中，5 年和 10 年 CSS 估计值分别为 89.2%和 76%。在 CSS 的多变量分析中，ISUP 分级组（p<0.001）、N 分期（p<0.001）、RP 治疗（危险比[HR]为 0.60，95%置信区间[CI]为 0.43-0.83，p<0.001）和患者年龄（p<0.05）与 CSS 改善相关。在 PSA≥50ng/ml 的所有患者和 RP 亚组中，PSA 未能保留其 CSS 的独立预后价值。
接受局部治疗的 PSA 水平极高的 nmPCa 患者具有相对较好的长期肿瘤学结局。因此，在选择良好的 nmPCa 患者中，高 PSA 水平本身不应排除根治性局部治疗的应用。潜在的选择偏差限制了在这种情况下对特定局部治疗方法的相对有效性的推断。
