Natural History Of Persistently Elevated Prostate Specific Antigen After Radical Prostatectomy: Results From The SEARCH Database

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology
Article Date: 01 Dec 2009 - 1:00 PDT

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UroToday.com - A prostate specific antigen (PSA) level that does not nadir after radical prostatectomy (RP) suggests residual benign or malignant local disease, or metastatic disease that occurred prior to surgery. In the November 2009 online edition of the Journal of Urology, Dr. Daniel Moreira and colleagues used ultra-sensitive PSA testing to identify post-RP persistent PSA levels and the natural history in these patients. An ultra-sensitive PSA level of 0.03ng/ml defined persistent disease.

This SEARCH study cohort included 1,156 prostate cancer (CaP) patients who were treated at 4 VA medical centers between 1998 and 2008. Earlier patients were excluded as the ultra-sensitive PSA test was not available. The nadir PSA was defined as the lowest PSA level between 1 and 6 months after RP but prior to biochemical recurrence. Biochemical recurrence was defined as a PSA level greater than 0.2ng/ml or secondary treatment for an increasing PSA. Patients who had at least 2 PSA values separated by at least 3 months had a PSA doubling time (PSADT) determined. Baseline patient and disease characteristics were compared between men with and without a PSA recurrence. Multivariate predictors of PSA recurrence and all cause mortality in men with PSA persistence were analyzed.

The number of PSA recurrences was 291 out of 1,156 men (25%) with a median PSA follow-up of 38 months. In comparison with men who had a PSA nadir of <0.03ng/ml, patients with persistently elevated PSA had significantly higher preoperative PSA, higher grade pathological Gleason score, positive surgical margins, extracapsular extension and seminal vesicle invasion. Even a PSA nadir of 0.2ng/ml or less was associated with an increased risk of biochemical recurrence. Men with PSA persistence had worse all cause mortality than men without PSA persistence. For men with PSA persistence and a nadir PSA of 0.2ng/ml or less, the 1, 3, 5 year risk of biochemical recurrence-free survival was 68%, 44%, and 36%, compared with 95%, 78%, and 72% for those without PSA persistence. The 1, 5, and 10 year overall survival probability in all men with persistently elevated PSA was 99%, 91%, and 63% compared with 99%, 92%, and 80% in men without PSA persistence. Multivariate predictors of PSA recurrence in men with PSA persistence and a nadir of 0.2ng/ml or less were a higher PSA nadir, positive surgical margins, and higher pathological Gleason score. Independently associated overall mortality variables in men with persistently elevated PSA include higher PSA nadir and seminal vesical invasion. PSA nadir was sub-divided into 4 cutoff groups and men with a PSA nadir of 0.4ng/ml or greater were at significantly increased risk for all cause mortality. There was no correlation between PSA persistence and PSADT.

Moreira DM, Presti JC Jr, Aronson WJ, Terris MK, Kane CJ, Amling CL, Fredland SJ

J Urol. 2009 Nov;182(5):2250-6.
doi:10.1016/j.juro.2009.07.022
Written by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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