Extended PSA Monitoring Post-Prostatectomy May Reduce Overtreatment, Study Finds
Investigators found that higher persistent PSA levels after surgery were linked to a worse prognosis, underscoring the importance of timing in post-operative care.
Conceptual image for viral etiology of prostate cancer: © Dr_Microbe - stock.adobe.com
Extending the monitoring period of prostate-specific antigen (PSA) levels for at least 3 months post radical prostatectomy (RP) may minimize overtreatment and improve patients’ outcomes. Investigators from the University Hospital Hamburg Eppendorf in Germany and Brigham and Women’s Hospital in Boston, Massachusetts found that higher persistent PSA levels after surgery were linked to a worse prognosis, underscoring the importance of timing in post-operative care.1
The study, published in JAMA Oncology, challenges the traditional practice of monitoring PSA levels for only 1.5 to 2 months after RP. According to the researchers, this shorter timeframe may lead to premature conclusions about cancer recurrence, potentially resulting in overtreatment.
“Checking the PSA level too soon can lead clinicians to mislabel a patient as having recurred and prompt referral to radiation and medical oncologists to initiate salvage radiation and hormonal therapy,” said senior author Anthony D’Amico, MD, PhD, chief of Genitourinary Radiation Oncology at Brigham and Women’s Hospital in Boston, Massachusetts, in a news release.2
The study analyzed data from 43,298 men with prostate cancer to evaluate the impact of pre-surgery PSA levels and persistent PSA after RP on prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM).
Key findings demonstrated that patients with undetectable PSA levels after surgery had significantly lower risks of PCSM and ACM compared with those patients who had persistent PSA. Among patients with persistent PSA, those with a pre-surgery PSA level greater than 20 ng/mL had a 59% lower risk of PCSM (adjusted HR, 0.41; 95% CI, 0.25-0.66; P < .001) and a 31% lower risk of ACM (adjusted HR, 0.69; 95% CI, 0.51-0.91; P = .01) compared with those with pre-surgery PSA levels of 20 ng/mL or less.
Conversely, increasing persistent PSA levels were associated with higher risks of ACM (adjusted HR, 1.14; 95% CI, 1.04-1.24; P = .004) and PCSM (adjusted HR, 1.27; 95% CI, 1.12-1.45; P < .001).
Study Details
Investigators reported that 29,043 patients overall had undetectable PSA levels after RP at the first assessment. Of those, 2743 patients had a PSA greater than 20 ng/mL, and 26,300 had a PSA level of 20 ng/mL or less. They also identified 1418 patients with a persistent PSA level post RP at the first assessment. Of these, 446 had a PSA level greater than 20 ng/mL and 973 had a PSA of 20 ng/mL or less.
An increasing persistent PSA level was significantly associated with increased ACM risk (adjusted HR,1.14; 95%CI,1.04-1.24; P = .004) and PCSM risk (adjusted HR,1.27; 95%CI,1.12-1.45; P < .001).
For patients with a pre-RP PSA greater than 20 ng/mL, these risks were reduced (ACM risk: adjusted HR,0.71; 95%CI,0.49-1.04; P = .08; PCSM risk: adjusted HR, 0.44; 95% CI, 0.24-0.71; P = .002), according to investigators.
After a median follow-up of 6.2 years (range, 3.6-10.3), among 30,461 patients, a significant interaction was observed between a persistent PSA vs undetectable PSA post-RP and a pre-RP PSA level greater than 20 ng/mL vs 20 ng/mL or less.
Investigators noted the significant association between a pre-RP PSA level greater than 20 ng/mL (vs 20 ng/mL or less), and a reduced ACM risk (adjusted HR,0.69; 95% CI,0.51-0.91; P = .01) and PCSM risk (adjusted HR,0.41; 95% CI,0.25-0.66; P < .001) in patients with a persistent PSA.
After a median follow-up of 6.0 years (range, 3.6-9.0), an increasing persistent PSA level was significantly associated with increased ACM risk (adjusted HR, 1.14; 95% CI, 1.04-1.24; P = .004) and PCSM risk (adjusted HR, 1.27; 95% CI, 1.12-1.45; P < .001). In contrast, for patients with a pre-RP PSA greater than 20 ng/mL, these risks were reduced (ACM risk: adjusted HR,0.71; 95% CI,0.49-1.04; P = .08; PCSM risk: adjusted HR, 0.44; 95% CI, 0.24-0.71; P = .002).
“The clinical significance of these findings is that they highlight the need to monitor PSA after surgery for longer than the commonly practiced 1.5 to 2 months before concluding that PSA levels are persistent and initiating additional therapy,” said D’Amico.
