Subtract 2 if you had addon adjuvant radiation treatment

Add the numbers. Your chances that your cancer will recur, as measured by rising PSA five years following surgery, are shown in Table 7.

Additional nomograms, developed by Michael Kattan and his colleagues at Memorial Sloan-Kettering Cancer Center in New York, are widely used by physicians and are commonly referred to as Kat-tan tables.4 The nomograms utilize information such as size of the cancer and evidence of invasion at surgery, or radiation dose and length of radiation therapy. A major shortcoming of all systems is that they are based on the experience of men treated in past years, whereas treatments are continuing to improve and past experience may not necessarily be applicable.

There are three main stages in the recurrence and spread of prostate cancer:

1. Recurrence as measured by PSA: As noted in Chapters 3 and 4, a rise in the PSA after surgical or radiation treatment indicates recurrence of cancer. In the medical literature, this increase is commonly referred to as a biochemical failure. If the PSA is going to rise in a postsurgical patient, it will do so within the first five years in 72 percent of cases; between five and ten years in 23 percent of cases; and between ten and fifteen years in 5 percent of cases. It is rare to have a recurrence of cancer beyond fifteen years. Or we might say that the average time from surgery to a rising PSA is three and a half years.5

Once the cancer has recurred, as indicated by a rise in the PSA, its progression is highly variable. If no treatment is given, the PSA will continue to rise relatively rapidly in approximately half of all men, slowly in a third of men, and very slowly in the remainder. In 7 percent of cases, the PSA will not reach a level of 10 in less than twenty years.6 Thus, some men will have a continuously rising PSA and progression of their cancer, while others will have almost no progression for many years despite receiving no treatment.

Table 7. Nomogram for Predicting Recurrence of Cancer Five Years Following Surgery

Total points Percent recurrence

23 33 40 48 60 68

9 10 11 12

13 or more

2. Progression from PSA rise to metastasis: The single best predictor of the continuing progression of recurrent prostate cancer is the PSA doubling time. As the name implies, this is the time it takes for the PSA level to go, for example, from 1.1 to 2.2 or 4.2 to 8.4. The shorter the doubling time, the worse the prognosis for men treated by either surgery or radiation. If the PSA doubles in less than six months, it is likely that the cancer has already metastasized to bones or other organs; if it doubles in more than twelve months, the cancer is probably still localized near the prostate bed.

Charles Pound and his colleagues at Johns Hopkins University developed predictions of how long it takes recurrent prostate cancer to metastasize once the PSA has risen, based on the PSA doubling time, Gleason score, and whether the initial PSA rise occurred sooner than two years after surgery (see Table 8).7

Having a shorter PSA doubling time doubles the chances that a man will have metastases by seven years after the PSA rise, other things being equal. Note that these predictions are a best-case scenario, since they represent the outcome for 304 men who were an average age of 58 when operated on for prostate cancer. There is evidence that younger men with prostate cancer have a better prognosis, so older men are likely to have a higher rate of metastasis than these numbers predict. Among the men followed at Johns Hopkins, the median time from PSA rise to metastasis was eight years, but varied from two to twelve years.

3. Progression from metastasis to death: The interval between the

Table 8. Percentage of Prostate Cancers That Will Have Spread to Bones or Other Organs, as Predicted by PSA Doubling Time, Gleason Score, and How Quickly the PSA Rose Following Surgery

PSA doubling time:

Gleason scores 5-7; PSA rise more than two years after surgery

more than 10 months less than 10 months

at 3 years at 5 years at 7 years

5% 14% 18% 18% 31% 40%

PSA doubling time:

Gleason scores 5-7; PSA rise less than two years after surgery

more than 10 months less than 10 months

at 3 years at 5 years at 7 years

21% 24% 41% 19% 65% 85%

Gleason scores 8-10; PSA rise more than two years after surgery

at 3 years at 5 years at 7 years 23% 40% 53%

Gleason scores 8-10; PSA rise less than two years after surgery

at 3 years at 5 years at 7 years 47% 69% 79%

note: The numbers are based on 304 men who had a rise in their PSA following radical prostatectomy at Johns Hopkins Hospital between 1982 and 1997. The average age of the men at surgery was 58. Younger men generally have a more benign course than older men; thus, these predictions may be overly optimistic for older men. source: C. R. Pound, A. W. Partin, M. A. Eisenberger, et al., Natural history of progression after PSA elevation following radical prostatectomy, Journal of the American Medical Association 281 (1999): 1591-97.

note: The numbers are based on 304 men who had a rise in their PSA following radical prostatectomy at Johns Hopkins Hospital between 1982 and 1997. The average age of the men at surgery was 58. Younger men generally have a more benign course than older men; thus, these predictions may be overly optimistic for older men. source: C. R. Pound, A. W. Partin, M. A. Eisenberger, et al., Natural history of progression after PSA elevation following radical prostatectomy, Journal of the American Medical Association 281 (1999): 1591-97.

development of prostate cancer metastases and death averages three to five years in various studies. In the Johns Hopkins study cited above, the median time was five years, but as noted, it was a study of younger men. The Pound group found that the shorter the interval between surgery and the development of metastases, the shorter the time to death was likely to be. For example, among men who developed metastases within three years of surgery, 87 percent had died by five years after their surgery.8

Stages of Disease

The distinction between stages of disease is an arbitrary one. There is no single moment when Victor's cancer ceased to be something he lived with and became, instead, something that was killing him. It was killing him from the beginning and he lived with it until the end. Still, there is some reason to divide the experience into periods. There was a time when Victor lived a more or less normal life despite the disease, and it was followed by a period that was not like normal life at all, when we understood that his life itself was nearing its end. There was no defining moment that separated one period from the other, but they were nonetheless different.

—Audrey Newton, Living with Prostate Cancer

In summary, the sooner the PSA rises following treatment for prostate cancer, the worse the prognosis. Thereafter, the faster the PSA doubling time, the sooner the man is likely to develop metastases. And the sooner he develops metastases, the sooner he is likely to die. The duration from initial treatment to rise in PSA averages three to four years but may be as long as fifteen years. The duration from PSA rise to metastasis averages six to eight years, and from metastasis to death three to five years. Thus, for men whose cancer appears not to have spread at the time of initial diagnosis, the average time between initial treatment and death will be approximately fifteen years for those who are destined to die from their cancer. This prediction is not valid for men whose cancer has already spread at the time of initial diagnosis.

Always keep in mind, however, that predictions are merely predictions. As in all recurrent cancers, one subgroup progresses very rapidly, one subgroup progresses hardly at all, and the vast majority of men fall between these two extremes. There are always those who defy predictions. Consider the 45-year-old man who in 1976 was diagnosed with prostate cancer that had already metastasized to his bones and distant lymph nodes. He was treated with hormone therapy and twenty-seven years later was still doing fine.9 All of us who have prostate cancer hope that we too will do better than the average predictions.

10 Ways To Fight Off Cancer

10 Ways To Fight Off Cancer

Learning About 10 Ways Fight Off Cancer Can Have Amazing Benefits For Your Life The Best Tips On How To Keep This Killer At Bay Discovering that you or a loved one has cancer can be utterly terrifying. All the same, once you comprehend the causes of cancer and learn how to reverse those causes, you or your loved one may have more than a fighting chance of beating out cancer.

Get My Free Ebook


Post a comment