Article of the Week: The impact of PSMs on long-term outcomes after RP

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Prabhakar Mithal, discussing his paper.

If you only have time to read one article this week, it should be this one.

Positive Surgical Margins in Radical Prostatectomy Patients Do Not Predict Long-term Oncological Outcomes: Results from SEARCH

Prabhakar Mithal, Lauren E. Howard†‡, William J. Aronson§¶, Martha K. Terris**††, Matthew R. Cooperberg‡‡, Christopher J. Kane§§, Christopher Amling¶¶ and Stephen J. Freedland‡***

Department of Urology, University of Rochester Medical Center, Rochester, NY, †Department of Biostatistics and Bioinformatics, Duke University School of Medicine, ‡Division of Urology, Veterans Affairs Medical Center, Durham, NC, §Urology Section, Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, ¶Department of Urology, UCLA School of Medicine, Los Angeles, CA, **Section of Urology, Veterans Affairs Medical Center, ††Section of Urology, Medical College of Georgia, Augusta, GA, ‡‡Department of Urology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, §§Urology Department, University of California San Diego Health System, San Diego, CA , ¶¶Division of Urology, Department of Surgery, Oregon Health and Science University, Portland, OR , and ***Division of Urology, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA

Read the full article

Objective

To assess the impact of positive surgical margins (PSMs) on long-term outcomes after radical prostatectomy (RP), including metastasis, castrate-resistant prostate cancer (CRPC), and prostate cancer-specific mortality (PCSM).

Patients and Methods

Retrospective study of 4 051 men in the Shared Equal Access Regional Cancer Hospital (SEARCH) cohort treated by RP from 1988 to 2013. Proportional hazard models were used to estimate hazard ratios (HRs) of PSMs in predicting biochemical recurrence (BCR), CRPC, metastases, and PCSM. To determine if PSMs were more predictive in certain patients, analyses were stratified by pathological Gleason score, stage, and preoperative prostate-specific antigen (PSA) level.

Results

The median (interquartile range) follow-up was 6.6 (3.2–10.6) years and 1 127 patients had >10 years of follow-up. During this time, 302 (32%) men had BCR, 112 (3%) developed CRPC, 144 (4%) developed metastases, and 83 (2%) died from prostate cancer. There were 1 600 (40%) men with PSMs. In unadjusted models, PSMs were significantly associated with all adverse outcomes: BCR, CRPC, metastases and PCSM (all P ≤ 0.001). After adjusting for demographic and pathological characteristics, PSMs were associated with increased risk of only BCR (HR 1.98, P < 0.001), and not CRPC, metastases, or PCSM (HR ≤1.29, P > 0.18). Similar results were seen when stratified by pathological Gleason score, stage, or PSA level, and when patients who underwent adjuvant radiotherapy were excluded.

Conclusions

PSMs after RP are not an independent risk factor for CRPC, metastasis, or PCSM overall or within any subset. In the absence of other high-risk features, PSMs alone may not be an indication for adjuvant radiotherapy.