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New Method to Assess Risk of Advanced Cancer After Prostate Removal
Study Could Benefit Drug Trials
Published in Journal of the American Medical Association, May 5, 1999
Reference: JAMA, vol.281 pages 1591-1597
Pound CP, Partin AW, Eisenberger MA, Chan DW, Pearson JD and Walsh PC.

"THE NATURAL HISTORY OF PROGRESSION FOLLOWING PSA RECURRENCE AFTER RADICAL PROSTATECTOMY"

This study fills a large gap in knowledge about the natural history of cancer in men who have had their prostates removed." -- Patrick C. Walsh, M.D., Professor and Chair of The Brady Urological Institute, The Department of Urology, The Johns Hopkins Medical Institution, Baltimore, MD 21287.

While prostate removal cures most men of their prostate cancer, about 35 percent show a rise in their prostate specific antigen (PSA) levels in the 10 years following surgery, an early sign that cancer may be returning. Now, in the largest and longest study of its kind, urologists at Johns Hopkins have developed a simple method for assessing the risk these men have for developing deadly metastatic cancer.

"The first thing patients want to know after their PSA rises following surgery is how long they have to live," says Patrick Walsh, M.D., Hopkins Chief of Urology, who surgically removed the prostates of the two thousand patients in the study. "And the first thing doctors want to know is what type of treatment the patient needs. Up until now, there hasn't been any way to know."

In the most extensive follow-up study on the history of prostate cancer after surgery, Walsh and his colleagues compiled 10,000 patient-years of data from 1982-1997. From this information, they developed a chart doctors and patients can use to pinpoint the risk for developing metastatic cancer, which typically invades the bones of men with prostate cancer.

"Doctors used to say, 'You've recurred, but we aren't sure what that means,'" says Alan Partin, Ph.D., a co-author and Associate Professor of Urology at The Johns Hopkins Hospital on the study which appeared in the May 5, 1999 Journal of the American Medical Association. "Now they can say, 'You've recurred, and we know your risk for developing advanced cancer.'"

The chart places men into different risk groups using three common measures: the Gleason score from the removed prostate (a measure of the cancer's severity); when the rise in PSA level occurred (either before or after two years post-surgery); and how long before their PSA level doubled (either greater or less than 10 months).

A man in the lowest risk group (with a moderately severe tumor, PSA recurrence after two years post-surgery, and PSA doubling time greater than 10 months) has a 95 percent chance of being metastasis-free three years after the PSA recurrence; an 86 percent chance at five years; and an 82 percent chance at seven years.

"When men see their PSA levels rise again, they think that means the cancer is back and they need to get treated right away. But that isn't always the case," says Mario Eisenberger, M.D., a Hopkins oncologist, Professor of Urological Oncology and study co-author. "Patients often live for years without having the cancer spread. This information will better equip doctors and their patients to decide what treatment, if any, is most appropriate."

The study is critical for future drug research as well, says Partin, because it provides essential baseline data. "Before, it was difficult to know if a drug was helping, because you couldn't be sure what the disease would have done on its own," he says. "Now, researchers can compare their treatment groups with our study group and tell if their treatment is improving survival."

Other findings from the study:

  • Men who experienced rising PSA (304 out of the 1,997 men) remained free from metastatic cancer an average of eight years.

  • After developing metastatic cancer, as confirmed by imaging techniques like bone scans, the average time to death was five years. However, men who developed metastasis eight or more years following surgery had a much better outlook.

  • At 15 years post-surgery, a projected 82 percent of men will still be free from metastatic cancer and considered cured.

The men were followed for an average of 5.3 years. A "PSA recurrence" was defined as a level greater than 0.2 nanograms/milliliter.

Graphic of radical prostatectomy - http://urology.jhu.edu/prostate/video1.php
Dr. Walsh's home page - http://urology.jhu.edu/patrickwalsh/
Dr. Partin's home page -http://urology.jhu.edu/alanpartin/

For more information and to receive a summary of this paper call 410-955-1504
Johns Hopkins Media Contact: Brian Vastag / 410-955-8665 / bvastag@jhmi.edu


How to use this information:

The three pieces of information you will need are (contact your surgeon/physician if you are unsure about these facts):

  1. The Gleason Score (a number from 2-10) taken by a pathologist from the tissue removed at the time of your radical prostatectomy.

  2. The time from your surgery to your first PSA which was above the level of detection (usually above 0.2 ng/mL) in years. You need to know if this time was greater or less than 2 years.

  3. The time in months that it has taken for your PSA to double - PSA Doubling time.

    1.0 If you have a Gleason score of 5-7


  • AND 1.1 Your Time to first PSA recurrence was greater than two years:

    • AND Your PSA doubling time was greater than 10 months:
      Chance of not developing metastasis (positive bone scan) in:
        Three years: 95%
        Five Years: 86%
        Seven Years: 82%
    • OR Your PSA doubling time was less than 10 months:
      Chance of not developing metastasis in:
        Three years: 82%
        Five Years: 69%
        Seven Years: 60%
  • OR  1.2 Your time to first PSA recurrence was less than 2 years:

    • AND Your PSA doubling time was greater than 10 months:

      Chance of not developing metastasis in:
        Three years: 79%
        Five Years: 76%
        Seven Years: 59%
    • OR Your PSA doubling time was less than 10 months:

      Chance of not developing metastasis in:
        Three years: 81%
        Five Years: 35%
        Seven Years: 15%

    2.0 If you have a Gleason score of 8-10 use this data:
    (Note: PSA doubling time not useful for Gleason 8-10)


  • AND
      2.2 If your time to first PSA recurrence was greater than two years:

      Chance of not developing metastasis in:
        Three years: 77%
        Five Years: 60%
        Seven Years: 47%
  • OR
      2.1 If your time to first PSA recurrence was less than 2 years:

      Chance of not developing metastasis in:
        Three years: 53%
        Five Years: 31%
        Seven Years: 21%
If you have questions about this data contact your physician.
 

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