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Johnston TJ, Shaw GL, Lamb AD, Parashar D, Greenberg D, Xiong T, Edwards AL, Gnanapragasam V, Holding P, Herbert P, Davis M, Mizielinsk E, Lane JA, Oxley J, Robinson M, Mason M, Staffurth J, Bollina P, Catto J, Doble A, Doherty A, Gillatt D, Kockelbergh R, Kynaston H, Prescott S, Paul A, Powell P, Rosario D, Rowe E, Donovan JL, Hamdy FC, Neal DE. Mortality Among Men with Advanced Prostate Cancer Excluded from the ProtecT Trial. Eur Urol 2016; 71:381-388. [PMID: 27720537 PMCID: PMC5289293 DOI: 10.1016/j.eururo.2016.09.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/26/2016] [Indexed: 11/21/2022]
Abstract
Background Early detection and treatment of asymptomatic men with advanced and high-risk prostate cancer (PCa) may improve survival rates. Objective To determine outcomes for men diagnosed with advanced PCa following prostate-specific antigen (PSA) testing who were excluded from the ProtecT randomised trial. Design, setting, and participants Mortality was compared for 492 men followed up for a median of 7.4 yr to a contemporaneous cohort of men from the UK Anglia Cancer Network (ACN) and with a matched subset from the ACN. Outcome measurements and statistical analysis PCa-specific and all-cause mortality were compared using Kaplan-Meier analysis and Cox's proportional hazards regression. Results and limitations Of the 492 men excluded from the ProtecT cohort, 37 (8%) had metastases (N1, M0 = 5, M1 = 32) and 305 had locally advanced disease (62%). The median PSA was 17 μg/l. Treatments included radical prostatectomy (RP; n = 54; 11%), radiotherapy (RT; n = 245; 50%), androgen deprivation therapy (ADT; n = 122; 25%), other treatments (n = 11; 2%), and unknown (n = 60; 12%). There were 49 PCa-specific deaths (10%), of whom 14 men had received radical treatment (5%); and 129 all-cause deaths (26%). In matched ProtecT and ACN cohorts, 37 (9%) and 64 (16%), respectively, died of PCa, while 89 (22%) and 103 (26%) died of all causes. ProtecT men had a 45% lower risk of death from PCa compared to matched cases (hazard ratio 0.55, 95% confidence interval 0.38–0.83; p = 0.0037), but mortality was similar in those treated radically. The nonrandomised design is a limitation. Conclusions Men with PSA-detected advanced PCa excluded from ProtecT and treated radically had low rates of PCa death at 7.4-yr follow-up. Among men who underwent nonradical treatment, the ProtecT group had a lower rate of PCa death. Early detection through PSA testing, leadtime bias, and group heterogeneity are possible factors in this finding. Patient summary Prostate cancer that has spread outside the prostate gland without causing symptoms can be detected via prostate-specific antigen testing and treated, leading to low rates of death from this disease.
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Affiliation(s)
| | - Greg L Shaw
- Academic Urology Group, University of Cambridge, Cambridge, UK; Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Cambridge, UK
| | - Alastair D Lamb
- Academic Urology Group, University of Cambridge, Cambridge, UK; Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Cambridge, UK
| | - Deepak Parashar
- Statistics and Epidemiology Unit & Cancer Research Centre, University of Warwick, Coventry, UK
| | - David Greenberg
- National Cancer Registration Service - Eastern Office, Public Health England, Cambridge, UK
| | - Tengbin Xiong
- Academic Urology Group, University of Cambridge, Cambridge, UK
| | | | | | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Michael Davis
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - J Athene Lane
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Mary Robinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - Malcolm Mason
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - John Staffurth
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Prasad Bollina
- Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Andrew Doble
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
| | - Alan Doherty
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Gillatt
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - Howard Kynaston
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Steve Prescott
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alan Paul
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Philip Powell
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Derek Rosario
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Edward Rowe
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David E Neal
- Academic Urology Group, University of Cambridge, Cambridge, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
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