F.H. Schröder

International Validation of a Preoperative Nomogram for Prostate Cancer Recurrence After Radical Prostatectomy

PURPOSE We evaluated the predictive accuracy of a recently published preoperative nomogram for prostate cancer that predicts 5-year freedom from recurrence. We applied this nomogram to patients from seven different institutions spanning three continents. METHODS Clinical data of 6,754 patients were supplied for validation, and 6,232 complete records were used. Nomogram-predicted probabilities of 60-month freedom from recurrence were compared with actual follow-up in two ways. First, areas under the receiver operating characteristic curves (AUCs) were determined for the entire data set according to several variables, including the institution where treatment was delivered. Second, nomogram classification-based risk quadrants were compared with actual Kaplan-Meier plots. RESULTS The AUC for all institutions combined was 0.75, with individual institution AUCs ranging from 0.67 to 0.83. Nomogram predictions for each risk quadrant were similar to actual freedom from recurrence rates: predicted probabilities of 87% (low-risk group), 64% (intermediate-low-risk group), 39% (intermediate-high-risk group), and 14% (high-risk group) corresponded to actual rates of 86%, 64%, 42%, and 17%, respectively. The use of neoadjuvant therapy, variation in the prostate-specific antigen recurrence definitions between institutions, and minor differences in the way the Gleason grade was reported did not substantially affect the predictive accuracy of the nomogram. CONCLUSION The nomogram is accurate when applied at international treatment institutions with similar patient selection and management strategies. Despite the potential for heterogeneity in patient selection and management, most predictions demonstrated high concordance with actual observations. Our results demonstrate that accurate predictions may be expected across different patient populations.

Very late local recurrence after surgery for prostate cancer unaccompanied by detectable PSA levels

The possibility and possible aetiology of local prostate cancer (PC) recurrence despite undetectable prostate-specific antigen (PSA) levels are highlighted. A case of a local recurrence 8.5 years after radical prostatectomy for Gleason 3+4 PC is presented. It demonstrates that PC can recur, even after a prolonged period of time (8.5 years), despite undetectable levels (i.e. <0.02 ng/ml) of PSA. In conclusion, the decision to omit digital rectal examination from the follow-up regimens of men with undetectable PSA levels could be justified. In such exceptional cases, however, PC recurrence would be either missed or would only be diagnosed after a considerable delay.

Een actief afwachtend beleid bij prostaatkanker: impact op de kwaliteit van leven

Tijdschrift voor Urologie mei 2012 nr. 3 Materiaal en methoden Prospectief werden er 150 Nederlandse PK-patiënten onder AS geïncludeerd. Deze patiënten ontvingen een vragenlijst op het moment van inclusie (t = 0), 9 maanden na diagnose (t = 9) en 18 maanden na diagnose (t = 18). Veranderingen in de volgende scores werden beoordeeld tussen t = 18 en t = 0: decisional conflict (DCS) met betrekking tot behandelkeuze, generieke angst (STAI-6), depressie (CES-D), PK-specifieke angst (MAX-PC), lichamelijke gezondheid (SF-12 PCS) en het zelfgeschatte risico op ziekteprogressie.

Under- and upgrading of prostate cancer after radical prostatectomy in a screening setting.

105 Background: It has been well established that there is an upward drift in assigned Gleason score (GS) to prostate cancer (PC) biopsies. However, few studies have examined the concordance between biopsy GS and pathological GS after radical prostatectomy (RP) in a screening setting over time. We assessed the proportion of under and upgrading of PC after RP by comparing the prevalence screen with the incidence screens from the European Randomized Study of Screening for Prostate Cancer (ERSPC), section Rotterdam. METHODS From 1993 to 1999, a total of 42.376 men identified from population registries in the Rotterdam region (55-74 yrs) were randomized into a screening or control arm. Men with PSA ≥3.0 ng/ml were recommended for sextant prostate biopsy, which were lateralized since 1996. The screening interval was 4 yrs. Men with screen-detected PC, who underwent RP within 1 yr, were eligible for this study. RESULTS In all, biopsy and pathological GS were known for 639 men who underwent RP. Of these RPs, 405 were performed between 1994 and 2000 (prevalence screen) whereas 235 cases were performed between 1998 and 2008 (incidence screens). In the prevalence screen, 49.8% of the biopsy GS matched the pathological GS ( Table ). This percentage improved to 58.3% in the incidence screens (p=0.045). The proportion of undergrading after RP was 23.0% in the prevalence screen, which declined to 16.2% in the incidence screens (p=0.049). Upgrading occurred in 27.2% of the cases in the prevalence and 25.5% in the incidence screens (p=0.71). CONCLUSIONS We have demonstrated an improved concordance between biopsy and pathological GS over time by comparing cancers detected in the prevalence screen with those detected in the incidence screens, which is in line with the upward shift of GS classification over time. In addition, significant less undergrading occurred in the incidence screens. However, one should keep in mind that within this screening program still a quarter of the biopsy GS were upgraded after RP in the incidence screens. [Table: see text] [Table: see text].

969 DISEASE SPECIFIC MORTALITY MAY UNDERESTIMATE THE TOTAL EFFECT OF PROSTATE CANCER SCREENING

0.42 men per 1000 person-years in the intervention and 0.48 men per 1000 person-years in the control arm: RR 0.86 (95% CI 0.64-1.17). The excess mortality rate was 0.40 per 1000 person- years in the intervention arm and 0.61 men per 1000 person-years in the control arm, and the RR for excess mortality was 0.66 (95% CI 0.39-1.13). Conclusions In contrast to the disease-specific mortality rates an increased difference in the excess mortality rates was observed between the two arms. This observation may be due to a systematic underestimation of the disease-specific deaths, and/or an additional disease-related mortality that is measured by an excess mortality analysis but not by a disease-specific mortality.