Cause-specific mortality of low and selective intermediate-risk prostate cancer patients with active surveillance or watchful waiting

Abstract

Background: Active surveillance or watchful waiting (AS/WW) is increasingly being used as an alternative strategy to radical prostatectomy or radiation therapy for appropriately selected patients with prostate cancer (PCa). However, the prognosis of low-risk and selective intermediate-risk PCa patients after AS/WW is poorly defined. In this study we reviewed the patients registered in the Surveillance, Epidemiology, and End Results (SEER) Program to establish a competing risk nomogram for the prediction of prostate cancerspecific mortality (PCSM). Methods: The information of patients undergoing AS/WW in the SEER program from 2004 to 2015 was obtained. All patients were ISUP (International Society of Urological Pathology) grade 1 or 2 PCa and also fulfilled the National Comprehensive Cancer Network's definition of low-risk PCa [prostate specific antigen (PSA) <10 ng/mL and cT2aN0M0 or less)]. A competing risk nomogram was used to analyze the association of tumor characteristics with PCSM and non-PCSM among the PCa patients with AS/WW. All cases were randomly divided into a training cohort and a validation cohort (1:1). A competing risk nomogram was constructed to predict PCSM in PCa patients with AS/WW. The performance of the PCSM nomogram was evaluated using the concordance index (C-index) and calibration curve. Results: A total of 30,538 PCa patients were identified as low risk or selective intermediate risk with AS/ WW. The 10-year cumulative incidence of death from prostate cancer and death from other cause were 2.8% (95% CI: 2.4-3.1%) and 19.3% (95% CI: 17.8-20.5%), respectively. Variables associated with PCSM included age, marital status, PSA, and ISUP grade. The PCSM nomogram had a good performance in both the training and validation cohorts, with a C-index of 0.744 (95% CI: 0.700-0.781, P<0.001) and 0.738 (95% CI: 0.700-0.777, P<0.001), respectively. Conclusions: Overall, the prognosis was favorable for the low-and selective intermediate-risk PCa patients with AS/WW. The competing risk nomogram yielded a good performance in identifying subgroups of patients with a higher risk of PCSM and potential candidates for AS/WW.

Clinical characteristics and prostate-cancer-specific mortality of competitive risk nomogram in the second primary prostate cancer

“…Of the 3,322 patients enrolled in our study, 16.28% of people died of spPCa. Compared with patients with only primary PCa, Wu et al (12) found that only 1.17% patients died of primary PCa, which was much lower than the proportion of PCa deaths (1.17% vs. 16.28%) in our study. In addition, compared with the mortality rate of primary prostate cancer (7.3%) by the International Agency for Research on Cancer estimates, the mortality rate of spPCa patients was significantly worse than that of primary prostate cancer patients.…”

“…The treatments of PCa mainly include waiting for active surveillance or watchful waiting (AS/WW), radical prostatectomy, and radical radiotherapy. Generally speaking, the main indications of AS/WW include T1–2, Gleason < 8, low tumor load at biopsy, life expectancy > 10 years, age > 70–75 years, and PSA lower than 10 ng/ml ( 12 ). However, a prospective study in the United States pointed out that active monitoring of low-risk PCa might cause patients to miss the best time for treatment, reducing their survival expectations ( 15 ).…”

A Nationwide Analysis of Risk of Prostate Cancer Diagnosis and Mortality following an Initial Negative Transrectal Ultrasound Biopsy with Long-Term Followup

“…Only a few studies have investigated this relationship, but results of other population-based analyses lead to speculation that rising PSA is also associated with other-cause mortality. 8,9,19–22 The explanation for this relationship is unclear, but there are several potential explanations. The most plausible explanation is a referral artifact: there is a lower propensity to PSA testing and taking of a biopsy in men who have comorbidities; such men are only likely to undergo a PSA test or biopsy if they represent themselves with clear clinical symptoms.…”

Variance of Tumor Grade at Radical Prostatectomy With Assessment of Each Tumor Nodule Versus Global Grading

“…This poses a potential challenge for drawing inferences from large multi-institutional databases that include institutions using different grading schemes if those institutions do not report the grading methodology used or the fractions of Gleason patterns present in a given RP. 25,26 Outcomes in Each Grade Group (GG) With Individual Tumor Nodule (TN) and Corresponding Global Grading Highest-Grade TN GG Highest-Grade TN Gleason Score Global GG Global Gleason Score…”