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A Preoperative Nomogram for Disease Recurrence Following Radical Prostatectomy for Prostate Cancer
354
BENIGN AND MALIGNANT NEOPLASMS OF PROSTATE Objective.-To develop risk assessment guidelines and a cutoff value for defining abnormal percentage of free PSA in a population of men to whom the test would be applied. Design.-Prospective blinded study using the Tandem PSA and free PSA assays (Hybritech Inc, San Diego, Calif). Setting.Seven nationwide university medical centers. Participants.-A total of 773 men (379 with prostate cancer, 394 with benign prostatic disease) 50 to 75 years of age with a palpably benign prostate gland, PSA level of 4.0 to 10.0 ng/mL, and histologically confirmed diagnosis. Main Outcome Measures.-A percentage of free PSA cutoff that maintained 95% sensitivity for prostate cancer detection, and probability of cancer for individual patients. Results.-The percentage of free PSA may be used in 2 ways: as a single cutoff (ie, perform a biopsy for all patients at or below a cutoff of 25% free PSA) or as an individual patient risk assessment (ie, base biopsy decisions on each patient’s risk of cancer). The 25%free PSA cutoff detected 95% of cancers while avoiding 20%of unnecessary biopsies. The cancers associated with greater than 25% free PSA were more prevalent in older patients, and generally were less threatening in terms of tumor grade and volume. For individual patients, a lower percentage of free PSA was associated with a higher risk of cancer (range, 8?’~-56%). In the multivariate model used, the percentage of free PSA was an independent predictor of prostate cancer (odds ratio [OR],3.2; 9 5 9 confidence interval [CI], 2.5-4.1; P < ,001) and contributed significantly more than age (OR, 1.2; 9 5 8 CI, 0.92-1.55) or total PSA level (OR, 1.0; 95% CI, 0.92-1.11) in this cohort of subjects with total PSA values between 4.0 and 10.0 ng/mL. Conclusions.-Use of the percentage of free PSA can reduce unnecessary biopsies in patients undergoing evaluation for prostate cancer, with a minimal loss in sensitivity in detecting cancer. A cutoff of 25%or less free PSA is recommended for patients with PSA values between 4.0 and 10.0 ng/mL and a palpably benign gland, regardless of patient age or prostate size. To our knowledge, this study is the largest series to date evaluating the percentage of free PSA in a population representative of patients in whom the test would be used in clinical practice.
Editorial Comment: This article provides further evidence that the percentage of free PSA enhances the specificity of PSA testing for the diagnosis of cancer. In men with PSA between 4 and 10 the probability of cancer is only 8%if the percentage of free PSA is greater than 25%. However, the probability of cancer increases to 56%if free PSA is between 0 and 10. However, in the intermediate ranges the discrimination is less impressive, that is there is a 28%probability of cancer with 10 to 15%free PSA, 2Wo probability with 15 to 20% and 16%probability with 20 to 25%.The specific cutoffs are also influenced by age, that is 2Wo for men 50 to 59,26%for those 60 to 69 and 28%for those 70 to 75 years old. Patrick C. Walsh, M.D.
A Preoperative Nomogram for Disease Recurrence Following Radical Prostatectomy for Prostate Cancer M.W. KATTAN,J. A. EASTHAM, A. M. F. STAPLETON, T. M. WHEELER AND P. T. SCARDINO, Information Technology Program, Matsunaga-Conte Prostate Cancer Research Center, Scott Department of Urology and Department of Pathology, Baylor College of Medicine and Methodist Hospital, Houston, Texas J. Natl. Cancer Inst., 90: 766-771, 1998 Background: Few published studies have combined clinical prognostic factors into risk profiles that can be used to predict the likelihood of recurrence or metastatic progression in patients following treatment of prostate cancer. We developed a nomogram that allows prediction of disease recurrence through use of preoperative clinical factors for patients with clinically localized prostate cancer who are candidates for treatment with a radical prostatectomy. Methods: By use of Cox proportional hazards regression analysis, we modeled the clinical data and disease follow-up for 983 men with clinically localized prostate cancer whom we intended to treat with a radical prostatectomy. Clinical data included pretreatment serum prostate-specific antigen levels, biopsy Gleason scores, and clinical stage. Treatment failure was recorded when there was clinical evidence of disease recurrence, a rising serum prostate-specific antigen level (two measurements of 0.4 ng/mL or greater and rising), or initiation of adjuvant therapy. Validation was performed on a separate sample of 168 men, also from our institution. Results: Treatment failure (i.e., cancer recurrence) was noted in 196 of the 983 men, and the patients without failure had a median follow-up of 30 months (range, 1-146 months). The 5-year probability of freedom from failure for the cohort was 73% (95%confidence interval = 690/0-76%). The predictions from the nomogram appeared accurate and discriminating, with a validation sample area under the receiver operating characteristic curve (i.e., comparison of the predicted probability with the actual outcome) of 0.79. Conclusions: A nomogram has been developed that can be used to predict the 5-year probability of treatment failure among men with clinically localized prostate cancer treated with radical prostatectomy.
BENIGN AND MALIGNANT NEOPLASMS OF PROSTATE
Editorial Comment: The Partin tables are often used preoperatively to predict the pathological stage of disease, which indirectly can be used to estimate the probability of cure. These authors have developed a nomogram that can be used preoperatively to predict the probability of having an undetectable PSA level 5 years following surgery. In their experience few patients have PSA failure after 5 years, which has not been our experience at Hopkins. The usefulness of these tables for a long interval needs to be evaluated. Patrick C. Walsh, M.D.
Does the Choice of Anesthetic Technique Affect the Recovery of Bowel Function After Radical Prostatectomy?
R. A. STEVENS, M. MIKAT-STEVENS, R. FLANIGAN, W. BEDFORD WATERS, P. FURRY, T. SHEIKH, K. FREY,M. OLSON AND B. KLEINMAN, Mayo Medical School, Jacksonville, Florida, Uniformed Services University of Health Sciences, Bethesda, Maryland, and Departments of Anesthesiology, Urology and Radiology, Loyola University, Chicago and Loyola University Medical Center, Maywood, Illinois Urology, 52: 213-218, 1998 Objectives. Return of bowel hnction afbr radical prostatectomy surgery may be the limiting factor in discharging these patients from the hospital. Recent studies have shown that postoperative epidural i n b i o n of bupivacaine decreases time to return of bowel function compared with intravenous and epidural morphine in patients after abdominal surgery. This study focuses on the role of the intraoperative anesthetic technique on recovery of bowel function, intraoperative blood loss, and the incidence of postoperative deep venous thrombosis (DVT) in patients undergoing radical retropubic prostatectomy and pelvic lymphadenectomy. Methods. Forty patients undergoing prostatectomy were randomized to either group A (general endotracheal anesthesia, including muscle relaxation and mechanical ventilation, followed by postoperative intravenous morphine patient-controlled analgesia) or group B (thoracic epidural anesthesia using bupivacaine, combined with “light” general anesthesia using a laryngeal mask airway and spontaneous ventilation, followed by epidural morphine analgesia). Intra- and postoperative data were collected on blood loss, volumes of crystalloid and colloid infused, blood transfused, duration of anesthesia and surgery, anesthetic and surgical complications, time t o recovery of bowel function, quality of postoperative pain control, and time to discharge from hospital. Each patient underwent lower extremity venous ultrasonography to detect DVT. Results. Twenty-one patients received general anesthesia and 19 received combined epidural and general anesthesia. Intraoperative blood loss was significantly lower in the epidural group, and times to first flatus and first bowel movement were also shorter in this group. There were no significant differences in duration of anesthesia or surgery, quality of postoperative analgesia, side effects of analgesia, or time to discharge from hospital. There was no DVT detected in any patient. Conclusions. The combined anesthetic technique of thoracic epidural anesthesia and “light” general anesthesia with spontaneous ventilation decreased intraoperative blood loss and shortened the time to return of bowel function. However, this earlier return of bowel function was not great enough to realize a difference in time to hospital discharge. There was no evidence of increased complications secondary to epidural anesthesia or of prolonged anesthetic time necessary to place epidural catheters.
Editorial Comment: This study confirms the value of epidurdspinal anesthesia in reducing intraoperative blood loss. Although patients who received epidural anesthesia had a more rapid recovery of bowel function, this result did not translate into a shorter hospital stay. Patrick C. Walsh, M.D.
Pelvic Muscle ExerciseE3iofeedback for Urinary Incontinence After Prostatectomy: An Education Program
M. MATHEWSON-CHAPMAN, University of Florida College of Nursing, Gainesuille, Florida J. Cancer Ed., 12: 218-223, 1997 Background. This study tested the effectiveness of pelvic muscle exercise (PME)with biofeedback in reducing the length of time urinary incontinence (UI)was experienced following a radical pmstatectomy for localized prostate cancer. Methods: FiRy-three men were randomly assigned to an education intervention group or a control group. The education group received instruction in PME/biofeedback and were given a PME p~-~tocol to perform t k times per week for 12 weeks. The control PUP did not receive instruction in PME technique. Both groups recoded urine losses in three-day bladder diaries, and 24hour pad tests were done in weeks 2,5,9, and 12 after surgery. Study variables included. 1) length of time urine loss was experienced, 2) episodes and frequency of urine loss; and 3) ounces of urine lost and number of pads used. Results. The PMElbiofeedback
355
BENIGN AND MALIGNANT NEOPLASMS OF PROSTATE Objective.-To develop risk assessment guidelines and a cutoff value for defining abnormal percentage of free PSA in a population of men to whom the test would be applied. Design.-Prospective blinded study using the Tandem PSA and free PSA assays (Hybritech Inc, San Diego, Calif). Setting.Seven nationwide university medical centers. Participants.-A total of 773 men (379 with prostate cancer, 394 with benign prostatic disease) 50 to 75 years of age with a palpably benign prostate gland, PSA level of 4.0 to 10.0 ng/mL, and histologically confirmed diagnosis. Main Outcome Measures.-A percentage of free PSA cutoff that maintained 95% sensitivity for prostate cancer detection, and probability of cancer for individual patients. Results.-The percentage of free PSA may be used in 2 ways: as a single cutoff (ie, perform a biopsy for all patients at or below a cutoff of 25% free PSA) or as an individual patient risk assessment (ie, base biopsy decisions on each patient’s risk of cancer). The 25%free PSA cutoff detected 95% of cancers while avoiding 20%of unnecessary biopsies. The cancers associated with greater than 25% free PSA were more prevalent in older patients, and generally were less threatening in terms of tumor grade and volume. For individual patients, a lower percentage of free PSA was associated with a higher risk of cancer (range, 8?’~-56%). In the multivariate model used, the percentage of free PSA was an independent predictor of prostate cancer (odds ratio [OR],3.2; 9 5 9 confidence interval [CI], 2.5-4.1; P < ,001) and contributed significantly more than age (OR, 1.2; 9 5 8 CI, 0.92-1.55) or total PSA level (OR, 1.0; 95% CI, 0.92-1.11) in this cohort of subjects with total PSA values between 4.0 and 10.0 ng/mL. Conclusions.-Use of the percentage of free PSA can reduce unnecessary biopsies in patients undergoing evaluation for prostate cancer, with a minimal loss in sensitivity in detecting cancer. A cutoff of 25%or less free PSA is recommended for patients with PSA values between 4.0 and 10.0 ng/mL and a palpably benign gland, regardless of patient age or prostate size. To our knowledge, this study is the largest series to date evaluating the percentage of free PSA in a population representative of patients in whom the test would be used in clinical practice.
Editorial Comment: This article provides further evidence that the percentage of free PSA enhances the specificity of PSA testing for the diagnosis of cancer. In men with PSA between 4 and 10 the probability of cancer is only 8%if the percentage of free PSA is greater than 25%. However, the probability of cancer increases to 56%if free PSA is between 0 and 10. However, in the intermediate ranges the discrimination is less impressive, that is there is a 28%probability of cancer with 10 to 15%free PSA, 2Wo probability with 15 to 20% and 16%probability with 20 to 25%.The specific cutoffs are also influenced by age, that is 2Wo for men 50 to 59,26%for those 60 to 69 and 28%for those 70 to 75 years old. Patrick C. Walsh, M.D.
A Preoperative Nomogram for Disease Recurrence Following Radical Prostatectomy for Prostate Cancer M.W. KATTAN,J. A. EASTHAM, A. M. F. STAPLETON, T. M. WHEELER AND P. T. SCARDINO, Information Technology Program, Matsunaga-Conte Prostate Cancer Research Center, Scott Department of Urology and Department of Pathology, Baylor College of Medicine and Methodist Hospital, Houston, Texas J. Natl. Cancer Inst., 90: 766-771, 1998 Background: Few published studies have combined clinical prognostic factors into risk profiles that can be used to predict the likelihood of recurrence or metastatic progression in patients following treatment of prostate cancer. We developed a nomogram that allows prediction of disease recurrence through use of preoperative clinical factors for patients with clinically localized prostate cancer who are candidates for treatment with a radical prostatectomy. Methods: By use of Cox proportional hazards regression analysis, we modeled the clinical data and disease follow-up for 983 men with clinically localized prostate cancer whom we intended to treat with a radical prostatectomy. Clinical data included pretreatment serum prostate-specific antigen levels, biopsy Gleason scores, and clinical stage. Treatment failure was recorded when there was clinical evidence of disease recurrence, a rising serum prostate-specific antigen level (two measurements of 0.4 ng/mL or greater and rising), or initiation of adjuvant therapy. Validation was performed on a separate sample of 168 men, also from our institution. Results: Treatment failure (i.e., cancer recurrence) was noted in 196 of the 983 men, and the patients without failure had a median follow-up of 30 months (range, 1-146 months). The 5-year probability of freedom from failure for the cohort was 73% (95%confidence interval = 690/0-76%). The predictions from the nomogram appeared accurate and discriminating, with a validation sample area under the receiver operating characteristic curve (i.e., comparison of the predicted probability with the actual outcome) of 0.79. Conclusions: A nomogram has been developed that can be used to predict the 5-year probability of treatment failure among men with clinically localized prostate cancer treated with radical prostatectomy.
BENIGN AND MALIGNANT NEOPLASMS OF PROSTATE
Editorial Comment: The Partin tables are often used preoperatively to predict the pathological stage of disease, which indirectly can be used to estimate the probability of cure. These authors have developed a nomogram that can be used preoperatively to predict the probability of having an undetectable PSA level 5 years following surgery. In their experience few patients have PSA failure after 5 years, which has not been our experience at Hopkins. The usefulness of these tables for a long interval needs to be evaluated. Patrick C. Walsh, M.D.
Does the Choice of Anesthetic Technique Affect the Recovery of Bowel Function After Radical Prostatectomy?
R. A. STEVENS, M. MIKAT-STEVENS, R. FLANIGAN, W. BEDFORD WATERS, P. FURRY, T. SHEIKH, K. FREY,M. OLSON AND B. KLEINMAN, Mayo Medical School, Jacksonville, Florida, Uniformed Services University of Health Sciences, Bethesda, Maryland, and Departments of Anesthesiology, Urology and Radiology, Loyola University, Chicago and Loyola University Medical Center, Maywood, Illinois Urology, 52: 213-218, 1998 Objectives. Return of bowel hnction afbr radical prostatectomy surgery may be the limiting factor in discharging these patients from the hospital. Recent studies have shown that postoperative epidural i n b i o n of bupivacaine decreases time to return of bowel function compared with intravenous and epidural morphine in patients after abdominal surgery. This study focuses on the role of the intraoperative anesthetic technique on recovery of bowel function, intraoperative blood loss, and the incidence of postoperative deep venous thrombosis (DVT) in patients undergoing radical retropubic prostatectomy and pelvic lymphadenectomy. Methods. Forty patients undergoing prostatectomy were randomized to either group A (general endotracheal anesthesia, including muscle relaxation and mechanical ventilation, followed by postoperative intravenous morphine patient-controlled analgesia) or group B (thoracic epidural anesthesia using bupivacaine, combined with “light” general anesthesia using a laryngeal mask airway and spontaneous ventilation, followed by epidural morphine analgesia). Intra- and postoperative data were collected on blood loss, volumes of crystalloid and colloid infused, blood transfused, duration of anesthesia and surgery, anesthetic and surgical complications, time t o recovery of bowel function, quality of postoperative pain control, and time to discharge from hospital. Each patient underwent lower extremity venous ultrasonography to detect DVT. Results. Twenty-one patients received general anesthesia and 19 received combined epidural and general anesthesia. Intraoperative blood loss was significantly lower in the epidural group, and times to first flatus and first bowel movement were also shorter in this group. There were no significant differences in duration of anesthesia or surgery, quality of postoperative analgesia, side effects of analgesia, or time to discharge from hospital. There was no DVT detected in any patient. Conclusions. The combined anesthetic technique of thoracic epidural anesthesia and “light” general anesthesia with spontaneous ventilation decreased intraoperative blood loss and shortened the time to return of bowel function. However, this earlier return of bowel function was not great enough to realize a difference in time to hospital discharge. There was no evidence of increased complications secondary to epidural anesthesia or of prolonged anesthetic time necessary to place epidural catheters.
Editorial Comment: This study confirms the value of epidurdspinal anesthesia in reducing intraoperative blood loss. Although patients who received epidural anesthesia had a more rapid recovery of bowel function, this result did not translate into a shorter hospital stay. Patrick C. Walsh, M.D.
Pelvic Muscle ExerciseE3iofeedback for Urinary Incontinence After Prostatectomy: An Education Program
M. MATHEWSON-CHAPMAN, University of Florida College of Nursing, Gainesuille, Florida J. Cancer Ed., 12: 218-223, 1997 Background. This study tested the effectiveness of pelvic muscle exercise (PME)with biofeedback in reducing the length of time urinary incontinence (UI)was experienced following a radical pmstatectomy for localized prostate cancer. Methods: FiRy-three men were randomly assigned to an education intervention group or a control group. The education group received instruction in PME/biofeedback and were given a PME p~-~tocol to perform t k times per week for 12 weeks. The control PUP did not receive instruction in PME technique. Both groups recoded urine losses in three-day bladder diaries, and 24hour pad tests were done in weeks 2,5,9, and 12 after surgery. Study variables included. 1) length of time urine loss was experienced, 2) episodes and frequency of urine loss; and 3) ounces of urine lost and number of pads used. Results. The PMElbiofeedback
355