Background

Prostate cancer (PCa) patients with prostate-specific antigen (PSA) persistence after radical prostatectomy (RP) are at increased risk of mortality, although the natural history of these men is heterogeneous and the optimal management has not been established.

Objective

To develop a model to predict cancer-specific mortality (CSM) and to test the impact of radiotherapy (RT) on survival in this setting.

Design, setting, and participants

We identified 496 patients treated with RP and lymph node dissection at two referral centers between 1994 and 2014 who had PSA persistence, defined as a PSA level between 0.1 and 2 ng/ml at 6–8 wk after RP.

Outcome measurements and statistical analyses

A multivariable model predicting CSM was developed. We assessed whether the impact of postoperative PSA levels on survival differed according to baseline CSM risk. The nonparametric curve fitting method was then used to explore the relationship between baseline CSM risk and 10-yr CSM rates according to postoperative RT.

Results and limitations

Median follow-up for survivors was 110 mo. Overall, 49 patients experienced CSM. The 10-yr CSM-free survival was 88%. Pathologic grade group and pathologic stage were independent predictors of CSM (all p = 0.01). The association between CSM-free survival and PSA at 6–8 wk differed by the baseline CSM risk, whereby the effect of increasing PSA was evident only in patients with a CSM risk of ≥10%. Postoperative RT was beneficial when the predicted risk of CSM was ≥30% (p = 0.001 by an interaction test). Our study is limited by its retrospective design.

Conclusions

Increasing PSA levels should be considered as predictors of mortality exclusively in men with worse pathologic characteristics. Postoperative RT in this setting was associated with a survival benefit in patients with a CSM risk of ≥30%. Conversely, individuals with a CSM risk of <30% should be initially managed expectantly.

Patient summary

Not all patients with prostate-specific antigen persistence have a poor prognosis. Pathologic characteristics should be used to estimate the risk of cancer-specific mortality in these individuals and to identify patients who could benefit from postoperative radiotherapy.

中文翻译：

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前列腺癌根治性前列腺切除术后持久放高前列腺特异性抗原的男性患者术后放疗的影响：长期生存分析

背景

前列腺癌根治性前列腺切除术（RP）后前列腺特异性抗原（PSA）持续存在的前列腺癌（PCa）患者死亡风险增加，尽管这些男性的自然病史是异质的，并且尚未建立最佳治疗方案。

客观的

建立模型来预测癌症特异性死亡率（CSM）并测试放射治疗（RT）在这种情况下对生存的影响。

设计，设置和参与者

我们确定了1994年至2014年间在两个转诊中心接受RP和淋巴结清扫术治疗的496例患者，这些患者具有PSA持久性，定义为RP后6-8周的PSA水平在0.1和2 ng / ml之间。

成果测量和统计分析

建立了预测CSM的多变量模型。我们根据基线CSM风险评估了术后PSA水平对生存的影响是否有所不同。然后，根据术后RT，采用非参数曲线拟合方法探讨基线CSM风险与10年CSM率之间的关系。

结果与局限性

幸存者的中位随访时间为110 mo。总体而言，有49名患者经历了CSM。10年无CSM生存率为88％。病理分级组和病理分期是CSM的独立预测因子（所有p  = 0.01）。6-8周时无CSM生存率和PSA之间的关联因基线CSM风险而异，因此，仅在CSM风险≥10％的患者中，增加PSA的作用才明显。当预计的CSM风险≥30％时，术后放疗是有益的（ 通过交互作用试验，p = 0.001）。我们的研究受到其回顾性设计的限制。

结论

PSA水平升高应仅作为病理特征较差的男性的死亡率预测指标。在这种情况下，术后RT与CSM风险≥30％的患者的生存获益相关。相反，CSM风险小于30％的个体应得到初步管理。

病人总结

并非所有具有前列腺特异性抗原持续性的患者预后都较差。应当使用病理学特征来估计这些个体中因癌症而死亡的风险，并确定可以从术后放疗中受益的患者。