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Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer After Radical Prostatectomy

Andrew J. Stephenson, Peter T. Scardino, Michael W. Kattan, Thomas M. Pisansky, Kevin M. Slawin, Eric A. Klein, Mitchell S. Anscher, Jeff M. Michalski, Howard M. Sandler, Daniel W. Lin, Jeffrey D. Forman, Michael J. Zelefsky, Larry L. Kestin, Claus G. Roehrborn, Charles N. Catton, Theodore L. DeWeese, Stanley L. Liauw, Richard K. Valicenti, Deborah A. Kuban, Alan Pollack

From the Cleveland Clinic Foundation, Cleveland, OH; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic College of Medicine, Rochester, MN; Baylor College of Medicine; The University of Texas M.D. Anderson Cancer Center, Houston; The University of Texas Southwestern Medical Center, Dallas, TX; Duke University School of Medicine, Durham, NC; Washington University School of Medicine, St Louis, MO; University of Michigan Medical Center, Ann Arbor, MI; University of Washington School of Medicine, Seattle, WA; Wayne State University School of Medicine, Detroit, MI; William Beaumont Hospital, Royal Oak, MI; Princess Margaret Hospital, Toronto, Ontario, Canada; Johns Hopkins University School of Medicine, Baltimore, MD; University of Florida College of Medicine, Gainesville, FL; Thomas Jefferson University Medical College, Philadelphia, PA; and the Fox Chase Cancer Center, Philadelphia, PA

Address reprint requests to Andrew J. Stephenson, MD, Glickman Urological Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, A100, Cleveland, OH 44195-0001; e-mail: stephea2{at}ccf.org

Purpose An increasing serum prostate-specific antigen (PSA) level is the initial sign of recurrent prostate cancer among patients treated with radical prostatectomy. Salvage radiation therapy (SRT) may eradicate locally recurrent cancer, but studies to distinguish local from systemic recurrence lack adequate sensitivity and specificity. We developed a nomogram to predict the probability of cancer control at 6 years after SRT for PSA-defined recurrence.

Patients and Methods Using multivariable Cox regression analysis, we constructed a model to predict the probability of disease progression after SRT in a multi-institutional cohort of 1,540 patients.

Results The 6-year progression-free probability was 32% (95% CI, 28% to 35%) overall. Forty-eight percent (95% CI, 40% to 56%) of patients treated with SRT alone at PSA levels of 0.50 ng/mL or lower were disease free at 6 years, including 41% (95% CI, 31% to 51%) who also had a PSA doubling time of 10 months or less or poorly differentiated (Gleason grade 8 to 10) cancer. Significant variables in the model were PSA level before SRT (P < .001), prostatectomy Gleason grade (P < .001), PSA doubling time (P < .001), surgical margins (P < .001), androgen-deprivation therapy before or during SRT (P < .001), and lymph node metastasis (P = .019). The resultant nomogram was internally validated and had a concordance index of 0.69.

Conclusion Nearly half of patients with recurrent prostate cancer after radical prostatectomy have a long-term PSA response to SRT when treatment is administered at the earliest sign of recurrence. The nomogram we developed predicts the outcome of SRT and should prove valuable for medical decision making for patients with a rising PSA level.

Supported in part by National Cancer Institute Prostate Cancer SPORE grants (P50-CA92629, P50-CA97186, P50-CA58236), David Koch Fund, Leon Lowenstein Foundation. A.J.S. is supported in part by the American Foundation for Urologic Disease and National Institutes of Health T32-82088.

Presented in part at the 42nd Annual Meeting of the American Society of Clinical Oncology, Atlanta, GA, June 2-6, 2006.

This nomogram has been adapted for use on personal digital assistants and personal computers and is available in the public domain for free download at http://www.nomograms.org.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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