Department of Molecular Medicine and Surgery (Solna), Karolinska Institutet, Stockholm, Sweden.
Department of Urology and Kidney Transplantation, University of Foggia, Foggia, Italy.
JAMA Netw Open. 2023 Sep 5;6(9):e2332900. doi: 10.1001/jamanetworkopen.2023.32900.
Stratifying patients with biochemical recurrence (BCR) after primary treatment for prostate cancer based on the risk of prostate cancer-specific mortality (PCSM) is essential for determining the need for further testing and treatments.
To evaluate the association of BCR after radical prostatectomy or radiotherapy and its current risk stratification with PCSM.
DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study included a total of 16 311 male patients with 10 364 (64%) undergoing radical prostatectomy and 5947 (36%) undergoing radiotherapy with curative intent (cT1-3, cM0) and PSA follow-up in Stockholm, Sweden, between 2003 and 2019. Follow-up for all patients was until death, emigration, or end of the study (ie, December 31, 2018). Data were analyzed between September 2022 and March 2023.
Primary outcomes of the study were the cumulative incidence of BCR and PCSM. Patients with BCR were stratified in low- and high-risk according to European Association of Urology (EAU) criteria.
Radical prostatectomy or radiotherapy.
A total of 16 311 patients were included. Median (IQR) age was 64 (59-68) years in the radical prostatectomy cohort (10 364 patients) and 69 (64-73) years in the radiotherapy cohort (5947 patients). Median (IQR) follow-up for survivors was 88 (55-138) months and 89 (53-134) months, respectively. Following radical prostatectomy, the 15-year cumulative incidences of BCR were 16% (95% CI, 15%-18%) for the 4024 patients in the low D'Amico risk group, 30% (95% CI, 27%-32%) for the 5239 patients in the intermediate D'Amico risk group, and 46% (95% CI, 42%-51%) for 1101 patients in the high D'Amico risk group. Following radiotherapy, the 15-year cumulative incidences of BCR were 18% (95% CI, 15%-21%) for the 1230 patients in the low-risk group, 24% (95% CI, 21%-26%) for the 2355 patients in the intermediate-risk group, and 36% (95% CI, 33%-39%) for the 2362 patients in the high-risk group. The 10-year cumulative incidences of PCSM after radical prostatectomy were 4% (95% CI, 2%-6%) for the 1101 patients who developed low-risk EAU-BCR and 9% (95% CI, 5%-13%) for 649 patients who developed high-risk EAU-BCR. After radiotherapy, the 10-year PCSM cumulative incidences were 24% (95% CI, 19%-29%) for the 591 patients in the low-risk EAU-BCR category and 46% (95% CI, 40%-51%) for the 600 patients in the high-risk EAU-BCR category.
These findings suggest the validity of EAU-BCR stratification system. However, while the risk of dying from prostate cancer in low-risk EAU-BCR after radical prostatectomy was very low, patients who developed low-risk EAU-BCR after radiotherapy had a nonnegligible risk of prostate cancer mortality. Improving risk stratification of patients with BCR is pivotal to guide salvage treatment decisions, reduce overtreatment, and limit the number of staging tests in the event of PSA elevations after primary treatment.
对前列腺癌根治术后生化复发（BCR）患者进行风险分层至关重要，因为这有助于确定是否需要进一步检测和治疗。这种分层是基于前列腺癌特异性死亡率（PCSM）的风险。
评估根治性前列腺切除术或放疗后 BCR 及其当前风险分层与 PCSM 的关系。
设计、地点和参与者：这是一项基于人群的队列研究，共纳入了 16311 名男性患者，其中 10364 名（64%）接受根治性前列腺切除术，5947 名（36%）接受放疗（cT1-3、cM0），并在瑞典斯德哥尔摩进行 PSA 随访。随访时间从 2003 年至 2019 年。所有患者的随访时间截止至死亡、移民或研究结束（即 2018 年 12 月 31 日）。数据分析于 2022 年 9 月至 2023 年 3 月进行。
研究的主要结局是 BCR 和 PCSM 的累积发生率。根据欧洲泌尿外科学会（EAU）标准，将有 BCR 的患者分为低危和高危组。
根治性前列腺切除术或放疗。
共纳入 16311 名患者。根治性前列腺切除术队列（10364 名患者）的中位（IQR）年龄为 64（59-68）岁，放疗队列（5947 名患者）的中位（IQR）年龄为 69（64-73）岁。幸存者的中位（IQR）随访时间分别为 88（55-138）个月和 89（53-134）个月。在接受根治性前列腺切除术的患者中，4024 名低 D'Amico 风险组患者的 15 年 BCR 累积发生率为 16%（95%CI，15%-18%），5239 名中危 D'Amico 风险组患者的 15 年 BCR 累积发生率为 30%（95%CI，27%-32%），1101 名高危 D'Amico 风险组患者的 15 年 BCR 累积发生率为 46%（95%CI，42%-51%）。在接受放疗的患者中，1230 名低危组患者的 15 年 BCR 累积发生率为 18%（95%CI，15%-21%），2355 名中危组患者的 15 年 BCR 累积发生率为 24%（95%CI，21%-26%），2362 名高危组患者的 15 年 BCR 累积发生率为 36%（95%CI，33%-39%）。根治性前列腺切除术患者的 10 年 PCSM 累积发生率为低危 EAU-BCR 组 1101 名患者的 4%（95%CI，2%-6%）和高危 EAU-BCR 组 649 名患者的 9%（95%CI，5%-13%）。放疗后，低危 EAU-BCR 组 591 名患者的 10 年 PCSM 累积发生率为 24%（95%CI，19%-29%），高危 EAU-BCR 组 600 名患者的 10 年 PCSM 累积发生率为 46%（95%CI，40%-51%）。
这些发现表明 EAU-BCR 分层系统具有有效性。然而，虽然根治性前列腺切除术治疗后低危 EAU-BCR 患者死于前列腺癌的风险非常低，但接受放疗后低危 EAU-BCR 患者死于前列腺癌的风险不容忽视。改善 BCR 患者的风险分层对于指导挽救性治疗决策至关重要，可以减少过度治疗，并限制在原发治疗后 PSA 升高时进行分期检查的数量。
