When is a patient cured after prostatectomy?
One of the most frequently asked questions I hear from my patients following radical prostatectomy is: “Doc, am I cured now?” This is followed by: “What is my risk of recurrence?”
Leisenfeld et al address the issue of prognostic factors for late (>10 year postoperatively) biochemical recurrence (BCR). The authors reviewed records from the German Familial Prostate Cancer Database consisting of 10,310 patients who underwent radical prostatectomy (RP) alone between 1979 and 2015. Nearly 2,500 of those patients had an undetectable PSA for >10 years with a median follow-up of 12.8 years, 249 of these patients developed BCR after 10 years, and of those, 12 patients died of prostate cancer.
Not surprisingly, the authors found that the usual prognostic factors, such as high preoperative PSA, high pathologic Gleason sum, and extraprostatic extension, increased the risk of late BCR. They did not find that family history or sociodemographic factors were predictive of late recurrence. The 12 patients (or 36.4% of the late BCRs) who died of the disease should mandate annual PSA testing beyond 10 years.
I view this article with a much different perspective. If we look at the entire cohort of patients with an undetectable PSA at 10 years (2,480) and use the 12 patients who ultimately died from the disease, that equates to a cancer-specific mortality rate for the group of only 0.48%. That is a very low overall risk of dying from the disease.
While I am not prepared to tell my patients with an undetectable PSA that they are cured after 10 years following RP, I am a bit more pragmatic and selective as to whom I consider in need of continued follow-up. Consider a 78-year-old patient with multiple cardiac comorbidities and a healthy 63-year-old patient who comes to your clinic with his parents, for example, both with undetectable PSAs >10 years after RP. Is your level of concern the same?
Rather than making a blanket statement regarding continued follow-up, we need to consider the pathologic features commonly known to increase the risk of recurrence—concurrent medical problems, the patient’s age at recurrence, PSA doubling time, longevity in the family, etc. Certainly in men with none of these risk factors and very short life expectancy, I would question the need for continued annual PSAs.
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