Prostate cancer outcomes for men who present with symptoms at diagnosis

Abstract

OBJECTIVE: To compare clinical features, treatments and outcomes in men with non-metastatic prostate cancer (PCa) according to whether they were referred for symptoms or elevated prostate specific antigen (PSA). PATIENTS AND METHODS: This study used data from the South Australia Prostate Cancer Clinical Outcomes Collaborative database; a multi-institutional clinical registry covering both the public and private sectors. Participants included all non-metastatic cases from 1998-2013 referred for urinary/prostatic symptoms or elevated PSA. Multivariate Poisson regression was used to identify characteristics associated with symptomatic presentation and compare treatments according to reason for referral. Outcomes (i.e. overall survival, PCa survival, metastatic-free survival and disease-free survival) were compared using multivariate Cox proportional hazards and competing risk regression. RESULTS: Our analytic cohort consisted of 4841 men with localised PCa. Symptomatic men had lower risk disease (IR= 0.70, CI 0.61-0.81 for high vs low risk), fewer radical prostatectomies (IR=0.64 CI 0.56-0.75) and less radiotherapy (IR=0.86, CI 0.77-0.96) than men presenting with elevated PSA. All-cause mortality (HR=1.31, CI 1.16-1.47), disease-specific mortality (HR=1.42, CI 1.13-1.77) and risk of metastases (HR=1.36, CI 1.13-1.64) were higher for men presenting with symptoms, after adjustment for other clinical characteristics. However, risk of disease progression did not differ (HR=0.90, CI 0.74-1.07) amongst those treated curatively. Subgroup analyses indicated poorer PCa survival for symptomatic referral among men undergoing radical prostatectomy (HR=3.4, CI 1.3-8.8), those over 70 years (HR=1.4, CI 1.0-1.8), private patients (HR=2.1, CI 1.3-3.3), those diagnosed via biopsy (HR=1.3, CI 1.0-1.7) and those diagnosed before 2006 (HR=1.6, CI 1.1.2-1.7). CONCLUSION: Our results suggest that symptomatic presentation may be an independent negative prognostic indicator for PCa survival. More complete assessment of disease grade and extent, more definitive treatment and increased post-treatment monitoring among symptomatic cases may improve outcomes. Further research to determine any pathophysiological basis for poor outcomes in symptomatic men is warranted. This article is protected by copyright. All rights reserved.