Impact of prostate-specific antigen testing on the clinical and pathological outcomes after radical prostatectomy for Gleason 8-10 cancers

OBJECTIVE: To investigate whether the clinical and pathological outcomes after radical retropubic prostatectomy (RRP) have changed since the advent of prostate-specific antigen (PSA) testing for patients with Gleason 8-10 cancers. PATIENTS AND METHODS: We identified 584 men treated with RRP between 1988 and 2001 for pathological Gleason 8-10 tumours. Patients were divided for analysis by year of surgery, i.e. early (1988-93), mid (1994-97) and late PSA era (1998-2001). Survival rates after RRP were estimated using the Kaplan-Meier method, and the effect of clinicopathological factors on outcome was analysed using Cox proportional hazard regression models. RESULTS: The median preoperative PSA level decreased from 15 ng/mL in the early to 10 ng/mL in the late PSA era (P < 0.001), while the rate of organ-confined disease increased from 22.9% to 35.1% (P = 0.007). However, the 7-year biochemical recurrence-free (37% vs 45%, P = 0.087) and cancer-specific survival (89% to 91%, P = 0.73) did not change significantly from the early to the late PSA era. Increased preoperative PSA level (P < 0.001), seminal vesicle invasion (P < 0.001) and positive lymph nodes (P = 0.02) were associated with biochemical recurrence. Seminal vesicle invasion (P = 0.005), positive nodes (P < 0.001) and positive surgical margins (P = 0.03) predicted death from cancer. CONCLUSION: Although the pathological features of Gleason 8-10 cancers have become more favourable over the PSA era, survival has not changed. This lack of improvement in clinical outcome probably reflects the inherent biological aggressiveness of these cancers. While RRP provides long-term cancer control in a subset of these patients, continued investigation of multi-modal treatment options is warranted.