A new risk classification system for therapeutic decision making with intermediate-risk prostate cancer patients undergoing dose-escalated external-beam radiation therapy Journal Article


Authors: Zumsteg, Z. S.; Spratt, D. E.; Pei, I.; Zhang, Z.; Yamada, Y.; Kollmeier, M.; Zelefsky, M. J.
Article Title: A new risk classification system for therapeutic decision making with intermediate-risk prostate cancer patients undergoing dose-escalated external-beam radiation therapy
Abstract: Background The management of intermediate-risk prostate cancer (PCa) is controversial, in part due to the heterogeneous nature of patients falling within this classification. Objective We propose a new risk stratification system for intermediate-risk PCa to aid in prognosis and therapeutic decision making. Design, setting, and participants Between 1992 and 2007, 1024 patients with National Comprehensive Cancer Network intermediate-risk PCa and complete biopsy information were treated with definitive external-beam radiation therapy (EBRT) utilizing doses ≥81 Gy. Unfavorable intermediate-risk (UIR) PCa was defined as any intermediate-risk patient with a primary Gleason pattern of 4, percentage of positive biopsy cores (PPBC) ≥50%, or multiple intermediate-risk factors (IRFs; cT2b-c, prostate-specific antigen [PSA] 10-20, or Gleason score 7). Intervention All patients received EBRT with ≥81 Gy with or without neoadjuvant and concurrent androgen-deprivation therapy (ADT). Outcome measurements and statistical analysis Univariate and multivariate analyses were performed using a Cox proportional hazards model for PSA recurrence-free survival (PSA-RFS) and distant metastasis (DM). PCa-specific mortality (PCSM) was analyzed using a competing-risk method. Results and limitations Median follow-up was 71 mo. Primary Gleason pattern 4 (hazard ratio [HR]: 3.26; p < 0.0001), PPBC ≥50% (HR: 2.72; p = 0.0007), and multiple IRFs (HR: 2.20; p = 0.008) all were significant predictors of increased DM in multivariate analyses. Primary Gleason pattern 4 (HR: 5.23; p < 0.0001) and PPBC ≥50% (HR: 4.08; p = 0.002) but not multiple IRFs (HR: 1.74; p = 0.21) independently predicted for increased PCSM. Patients with UIR disease had inferior PSA-RFS (HR: 2.37; p < 0.0001), DM (HR: 4.34; p = 0.0003), and PCSM (HR: 7.39; p = 0.007) compared with those with favorable intermediate-risk disease, despite being more likely to receive neoadjuvant ADT. Short follow-up and retrospective study design are the primary limitations. Conclusions Intermediate-risk PCa is a heterogeneous collection of diseases that can be separated into favorable and unfavorable subsets. These groups likely will benefit from divergent therapeutic paradigms. © 2013 European Association of Urology.
Keywords: prostate cancer; risk stratification; intermediate risk; androgen deprivation; dose escalation
Journal Title: European Urology
Volume: 64
Issue: 6
ISSN: 0302-2838
Publisher: Elsevier Science, Inc.  
Date Published: 2013-12-01
Start Page: 895
End Page: 902
Language: English
DOI: 10.1016/j.eururo.2013.03.033
PROVIDER: scopus
PUBMED: 23541457
DOI/URL:
Notes: --- - Cited By (since 1996):2 - "Export Date: 2 December 2013" - "CODEN: EUURA" - "Source: Scopus"
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MSK Authors
  1. Zhigang Zhang
    240 Zhang
  2. Michael J Zelefsky
    616 Zelefsky
  3. Yoshiya Yamada
    357 Yamada
  4. Marisa A Kollmeier
    144 Kollmeier
  5. Zachary Stephan Zumsteg
    34 Zumsteg
  6. Daniel Eidelberg Spratt
    83 Spratt