(Pound et al. 1999)
Design: Retrospective case series (prognosis), evidence level: 3
Country: United States, setting: Tertiary care
Inclusion criteria Men with serum PSA elevation after radical prostatectomy. All patients were treated by a single surgeon at the same institution between 1982 and 1997.
Exclusion criteria Men who had adjuvant therapy prior to the development of metastasis were not included in the analysis of progression after PSA elevation. Men who had successful salvage radiotherapy (biochemical response of at least 2 years) were not included in this analysis.
Population number of patients = 1997.
Interventions Serial PSA measurement. Serial imaging, following biochemical relapse.
Outcomes Biochemical elevation, defined as a detectable serum PSA level of at least 0.2 ng/ml. Distant metastases were diagnosed by radionuclide bone scan, chest radiograph or other imaging, performed at the time of relapse and annually thereafter. Death was classified as: death with no evidence of disease, death with prostate cancer or death due to prostate cancer.
Follow up Median follow-up was 5.3 years, SD 3.7 years. Range was 0.5 to 15 years. After surgery, men were followed up with PSA assays and digital rectal examinations every 3 months for the first year, twice a year for the second year, and annually thereafter.
Results Metastasis free survival was 82% (95% CI, 76%–88%).
315/1997 (82%) of the men developed biochemical elevation, 11 of these were excluded from the analysis because of early adjuvant hormonal therapy.
104/315 (34%) of the men with biochemical elevation developed distant metastases. The median time to the development of metastases following PSA elevation was 8 years.
On univariate analysis (Wilcoxon-Gehan) prognostic factors for the development of distant metastases were: PSA doubling time of less than 10 months, prostatectomy Gleason score of 8 to 10, and short time to the PSA elevation (2 or less years after surgery) (p<0.001 for all prognostic factors).
44/105 (43%) of men who developed distant metastases died, in all cases the cause of death was prostate cancer. The only prognostic factor for death in this group was the time from surgery to development of metastases (the shorter the time the poorer the prognosis).
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General comments Longer follow-up and more appropriate analysis of this series in Freedland (2005)

From: Chapter 5 –The Management of Relapse After Radical Treatment

Cover of Prostate Cancer
Prostate Cancer: Diagnosis and Treatment.
NICE Clinical Guidelines, No. 58.
National Collaborating Centre for Cancer (UK).
Copyright © 2008, National Collaborating Centre for Cancer.

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