Prostate CancerPrognostic Implications of an Undetectable Ultrasensitive Prostate-Specific Antigen Level after Radical Prostatectomy
Introduction
Prostate-specific antigen (PSA) was introduced as a screening tool for prostate cancer in the late 1980s, and was recognized shortly thereafter as a surrogate biomarker for residual or recurrent disease [1], [2], [3], [4]. Assays that measure PSA to levels <0.1 ng/ml are denoted ultrasensitive PSA (USPSA) tests and are now widely available to clinicians. The utility of USPSA testing postprostatectomy has been the focus of some controversy in the urologic literature. Some authors claim that USPSA nadir values postprostatectomy are helpful in identifying cases of early biochemical relapse [5], [6], [7]. Others believe that USPSA offers minimal advantages and often causes an increase in anxiety in patients who are destined to have only clinically meaningless rises of USPSA [8].
Studies centered on the prognostic utility of an undetectable PSA postprostatectomy have not been widely reported. Our study hypothesizes that an undetectable USPSA as the initial test after radical prostatectomy (RP) will be a robust predictor of biochemical recurrence (BCR)–free survival regardless of clinical risk stratification or pathologic findings. As such, it may aid clinicians in determining who may either benefit by or forgo adjuvant therapy.
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Urologic Oncology Database
The Urologic Oncology Database (UODB) is a clinical and research resource in the Department of Urology at the University of California San Francisco (UCSF). The UODB contains diagnostic, surgical, pathologic, and clinical outcomes data on men treated for prostate cancer in the Urology Department at UCSF. Age, PSA history, biopsy findings, imaging and lab test results, surgical procedure and pathology details, BCR, secondary treatment, and mortality data are collected on patients who undergo RP
Baseline patient characteristics
Of 1674 patients who underwent RP in 1996–2006, 1323 received no neoadjuvant or adjuvant treatments and had pN0. Of those, 525 patients had at least 2 yr of postsurgery follow-up data, including ultrasensitive PSA values measured 1–3 mo after surgery. The median follow-up was 4.7 yr (range: 2.1–14.5 yr). There were 456 patients (87%) who had undetectable USPSA and 69 patients (13%) who had detectable USPSA immediately postprostatectomy. Most undetectable PSA values (n = 349) were ≤0.02 ng/ml.
Discussion
USPSA detection following RP has been shown to provide earlier detection of BCR than standard PSA measurements [5]. However, the prognostic ability of an undetectable USPSA has not been thoroughly evaluated. This study found that an undetectable USPSA 1–3 mo postoperatively was associated with a significant treatment failure advantage compared with men who have a detectable postoperative USPSA regardless of surgical margin status or pathologic stage.
The favorable prognosis of an undetectable
Conclusions
An undetectable USPSA after RP is a useful prognostic indicator of BCR-free survival at 5 yr that may aid in postoperative risk stratification and yield an earlier assessment of postoperative PSA kinetics. While an undetectable postoperative USPSA can reassure patients with unfavorable pathology, a detectable USPSA may cause unnecessary anxiety in patients who never suffer formal BCR.
References (30)
- et al.
Biochemical markers in prostatic cancer
Urol Clin North Am
(1984) - et al.
Ultrasensitive serum prostate specific antigen nadir accurately predicts the risk of early relapse after radical prostatectomy
J Urol
(2005) - et al.
Ultrasensitive detection of prostate specific antigen in the followup of 422 patients after radical prostatectomy
J Urol
(1999) - et al.
Variation in the definition of biochemical recurrence in patients treated for localized prostate cancer: the American Urological Association Prostate Guidelines for Localized Prostate Cancer Update Panel report and recommendations for a standard in the reporting of surgical outcomes
J Urol
(2007) - et al.
Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy. The 15-year Johns Hopkins experience
Urol Clin North Am
(2001) - et al.
Impact of positive surgical margins on prostate cancer recurrence and the use of secondary cancer treatment: data from the CaPSURE database
J Urol
(2000) - et al.
Influence of nerve-sparing (NS) procedure during radical prostatectomy (RP) on margin status and biochemical failure
Eur Urol
(2005) - et al.
Positive surgical margins in radical prostatectomy: outlining the problem and its long-term consequences
Eur Urol
(2009) - et al.
The actual value of the surgical margin status as a predictor of disease progression in men with early prostate cancer
Eur Urol
(2006) - et al.
Postoperative radiotherapy after radical prostatectomy: a randomised controlled trial (EORTC trial 22911)
Lancet
(2005)
Adjuvant radiotherapy for patients with locally advanced prostate cancer—a new standard?
Eur Urol
Timing of androgen deprivation therapy and its impact on survival after radical prostatectomy: a matched cohort study
J Urol
Prostate specific antigen recurrence after definitive therapy
J Urol
Natural history of biochemical recurrence after radical prostatectomy: risk assessment for secondary therapy
Eur Urol
Biochemical failure does not predict overall survival after radical prostatectomy for localized prostate cancer: 10-year results
Urology
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First Postprostatectomy Ultrasensitive Prostate-specific Antigen Predicts Survival in Patients with High-risk Prostate Cancer Pathology
2018, European Urology OncologyCitation Excerpt :Although the optimal use of uPSA has not yet been firmly established, use of the conventional cutoff of ≥0.2 ng/ml is flawed. As all the aforementioned uPSA studies have consistently shown [14–20], a substantial proportion of RP patients with “undetectable” PSA (<0.2 ng/ml) are in the process of relapsing. In one study, 23% of patients with undetectable PSA (<0.2 ng/ml) experienced BCR after 5 yr [21].
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