Survival outcomes of locally advanced prostate cancer in patients aged < 50 years after local therapy in the contemporary US population

How socioeconomic and clinical factors impact prostate-cancer-specific and other-cause mortality in prostate cancer stratified by clinical stage: Competing-risk analysis

BACKGROUND

The aim of this study was to analyze the causes of death and risk factors of prostate-cancer-specific mortality (PCSM) and other-cause mortality (OCM) at different clinical stages using data from the Surveillance, Epidemiology, and End Results database.

METHODS

The characteristics and cause-specific death classifications of males with prostate cancer (PCa) were extracted. Multivariate competing-risk regression analysis was used to identify significant predictors and quantify the cumulative incidence of PCSM and OCM at different clinical stages.

RESULTS

Of the 244,433 PCa patients who were included, 19,274 died from 7356 PCSM, and 11,918 from OCM. The proportion of PCSM gradually increased from 2010 to 2016. The risk factors for PCSM in the localized PCa stage included older age, not being married, living in a county with higher poverty rates, and higher PSA levels and Gleason scores. Meanwhile, Medicaid and lower education levels were the additional risk factors of OCM. The risk factors for PCSM in the regional PCa stage included older age, not being married, Medicaid, living in a county with higher poverty rates, and higher PSA levels and Gleason scores. Meanwhile, the income level did not affect OCM risk. The risk factors for PCSM in the distant metastatic PCa stage included a separated/divorced/widowed marital status, Medicaid, and higher PSA levels and Gleason scores. Meanwhile, older age, an unmarried or separated/divorced/widowed marital status, and higher PSA levels were risk factors for OCM. In addition, receiving both surgery and radiation was worse than just receiving surgery for PCa specific survival in localized and regional PCa patients.

CONCLUSION

Some pretreatment and treatment factors may influence OCM that are not identical to those for PCSM at the corresponding stage. Decision-makers and managers should fully consider OCM to maximize treatment benefits for PCa.

External validation of a magnetic resonance imaging-based algorithm for prediction of side-specific extracapsular extension in prostate cancer

Introduction

Recently developed algorithm for prediction of side-specific extracapsular extension (ECE) of prostate cancer required validation before being recommended to use. The algorithm assumed that ECE on a particular side was not likely with same side maximum tumor diameter (MTD) <15 mm AND cancerous tissue in ipsilateral biopsy <15% AND PSA <20 ng/mL (both sides condition). The aim of the study was to validate this predictive tool in patients from another department.

Material and methods

Data of 154 consecutive patients (308 prostatic lateral lobes) were used for validation. Predictive factors chosen in the development set of patients were assessed together with other preoperative parameters using logistic regression to check for their significance. Sensitivity, specificity, negative and positive predictive values were calculated for bootstrapped risk-stratified validation dataset.

Results

Validation cohort did not differ significantly from development cohort regarding PSA, PSA density, Gleason score (GS), MTD, age, ECE and seminal vesicle invasion rate. In bootstrapped data set (n = 200 random sampling) algorithm revealed 70.2% sensitivity (95% confidence interval (CI) 58.8–83.0%), 49.9% specificity (95%CI: 42.0–57.7%), 83.9% negative predictive value (NPV; 95%CI: 76.1–91.4%) and 31.1% positive predictive value (PPV; 95%CI: 19.6–39.7%). When limiting analysis to high-risk patients (Gleason score >7) the algorithm improved its performance: sensitivity 91%, specificity 47%, PPV 53%, NPV 89%.

Conclusions

Analyzed algorithm is useful for identifying prostate lobes without ECE and deciding on ipsilateral nerve-sparing technique during radical prostatectomy, especially in patients with GS >7. Due to significant number of false positives in case of: MTD ≥15 mm OR cancer in biopsy ≥15% OR PSA ≥20 ng/mL additional evaluation is necessary to aid decision-making.

Clinicopathological characteristics of localized prostate cancer in younger men aged ≤ 50 years treated with radical prostatectomy in the PSA era: A systematic review and meta-analysis

Objectives

With the rapid increase in younger age prostate cancer (PCa) patients, the impact of younger age on decision‐making for PCa treatment needs to be revaluated in the new era.

Materials and Methods

A systematic literature search was performed using PubMed, EMBASE, and Web of Science up to October 2019 to identify the eligible radical prostatectomy (RP) studies focusing on understanding the impact of age on clinicopathological features and oncological prognosis in patients with localized PCa in PSA era. Meta‐analyses were conducted using available hazard ratios (HRs) from both univariate and multivariate analyses.

Results

Twenty‐six studies including 391 068 patients with RP treatments from the PSA era were included. Of these studies, age of 50 years old (age50) is the most commonly used cut‐off age to separate the younger patient group (including either age < 50 or age ≤ 50) from the older patient group. In these studies, the incidence of younger patients varied between 2.6% and 16.6% with a median of 8.3%. Younger patients consistently showed more favorable clinicopathological features correlated with better BCR prognosis. Meta‐analyses showed a 1.38‐fold improved BCR survival of younger patients in multivariate analysis. Among the high‐risk PCa patients, younger age was independently associated with worse oncological outcomes in multivariate analyses.

Conclusion

In this study, we found younger age correlated with favorable clinicopathological characteristics and better BCR prognosis in low‐ to intermediate‐risk patients. In high‐risk group patients, younger patients often showed significantly worse oncological outcomes. Our study results suggest that age 50 could be used as a practical cut‐off age to separate younger age patients from older age PCa patients.

Benefits and Risks of Primary Treatments for High-risk Localized and Locally Advanced Prostate Cancer: An International Multidisciplinary Systematic Review

CONTEXT

The optimal treatment for men with high-risk localized or locally advanced prostate cancer (PCa) remains unknown.

OBJECTIVE

To perform a systematic review of the existing literature on the effectiveness of the different primary treatment modalities for high-risk localized and locally advanced PCa. The primary oncological outcome is the development of distant metastases at ≥5 yr of follow-up. Secondary oncological outcomes are PCa-specific mortality, overall mortality, biochemical recurrence, and need for salvage treatment with ≥5 yr of follow-up. Nononcological outcomes are quality of life (QoL), functional outcomes, and treatment-related side effects reported.

EVIDENCE ACQUISITION

Medline, Medline In-Process, Embase, and the Cochrane Central Register of Randomized Controlled Trials were searched. All comparative (randomized and nonrandomized) studies published between January 2000 and May 2019 with at least 50 participants in each arm were included. Studies reporting on high-risk localized PCa (International Society of Urologic Pathologists [ISUP] grade 4-5 [Gleason score {GS} 8-10] or prostate-specific antigen [PSA] >20 ng/ml or ≥ cT2c) and/or locally advanced PCa (any PSA, cT3-4 or cN+, any ISUP grade/GS) or where subanalyses were performed on either group were included. The following primary local treatments were mandated: radical prostatectomy (RP), external beam radiotherapy (EBRT) (≥64 Gy), brachytherapy (BT), or multimodality treatment combining any of the local treatments above (±any systemic treatment). Risk of bias (RoB) and confounding factors were assessed for each study. A narrative synthesis was performed.

EVIDENCE SYNTHESIS

Overall, 90 studies met the inclusion criteria. RoB and confounding factors revealed high RoB for selection, performance, and detection bias, and low RoB for correction of initial PSA and biopsy GS. When comparing RP with EBRT, retrospective series suggested an advantage for RP, although with a low level of evidence. Both RT and RP should be seen as part of a multimodal treatment plan with possible addition of (postoperative) RT and/or androgen deprivation therapy (ADT), respectively. High levels of evidence exist for EBRT treatment, with several randomized clinical trials showing superior outcome for adding long-term ADT or BT to EBRT. No clear cutoff can be proposed for RT dose, but higher RT doses by means of dose escalation schemes result in an improved biochemical control. Twenty studies reported data on QoL, with RP resulting mainly in genitourinary toxicity and sexual dysfunction, and EBRT in bowel problems.

CONCLUSIONS

Based on the results of this systematic review, both RP as part of multimodal treatment and EBRT + long-term ADT can be recommended as primary treatment in high-risk and locally advanced PCa. For high-risk PCa, EBRT + BT can also be offered despite more grade 3 toxicity. Interestingly, for selected patients, for example, those with higher comorbidity, a shorter duration of ADT might be an option. For locally advanced PCa, EBRT + BT shows promising result but still needs further validation. In this setting, it is important that patients are aware that the offered therapy will most likely be in the context a multimodality treatment plan. In particular, if radiation is used, the combination of local with systemic treatment provides the best outcome, provided the patient is fit enough to receive both. Until the results of the SPCG15 trial are known, the optimal local treatment remains a matter of debate. Patients should at all times be fully informed about all available options, and the likelihood of a multimodal approach including the potential side effects of both local and systemic treatment.

PATIENT SUMMARY

We reviewed the literature to see whether the evidence from clinical studies would tell us the best way of curing men with aggressive prostate cancer that had not spread to other parts of the body such as lymph glands or bones. Based on the results of this systematic review, there is good evidence that both surgery and radiation therapy are good treatment options, in terms of prolonging life and preserving quality of life, provided they are combined with other treatments. In the case of surgery this means including radiotherapy (RT), and in the case of RT this means either hormonal therapy or combined RT and brachytherapy.

Development and validation of a preoperative nomogram for predicting survival of patients with locally advanced prostate cancer after radical prostatectomy

Background

For selected locally advanced prostate cancer (PCa) patients, radical prostatectomy (RP) is one of the first-line treatments. We aimed to develop a preoperative nomogram to identify what kinds of patients can get the most survival benefits after RP.

Methods

We conducted analyses with data from the Surveillance, Epidemiology, and End Results (SEER) database. Covariates used for analyses included age at diagnosis, marital status, race, American Joint Committee on Cancer (AJCC) 7th TNM stage, Prostate specific antigen, Gleason biopsy score (GS), percent of positive cores. We estimated the cumulative incidence function for cause-specific death. The Fine and Gray’s proportional subdistribution hazard approach was used to perform multivariable competing risk analyses and reveal prognostic factors. A nomogram was built by these factors (including GS, percent of positive cores and N stage) and validated by concordance index and calibration curves. Risk stratification was established based on the nomogram.

Results

We studied 14,185 patients. N stage, GS, and percent of positive cores were the independent prognostic factors used to construct the nomogram. For validating, in the training cohort, the C-index was 0.779 (95% CI 0.736–0.822), and in the validation cohort, the C-index was 0.773 (95% CI 0.710–0.836). Calibration curves showed that the predicted survival and actual survival were very close. The nomogram performed better over the AJCC staging system (C-index 0.779 versus 0.764 for training cohort, and 0.773 versus 0.744 for validation cohort). The new stratification of risk groups based on the nomogram also showed better discrimination than the AJCC staging system.

Conclusions

The preoperative nomogram can provide favorable prognosis stratification ability to help clinicians identify patients who are suitable for surgery.