Vol. 40 (3): 316-321, May - June, 2014 ORIGINAL ARTICLE doi: 10.1590/S1677-5538.IBJU.2014.03.04 A 10-year analysis of metastatic prostate cancer as an initial presentation in an underserved population _______________________________________________ Andrew G. Winer, John P. Sfakianos, Llewellyn M. Hyacinthe, Brian K. McNeil Department of Urology, SUNY Downstate Medical Center and Kings County Medical Center, Brooklyn, NY, USA ABSTRACT ARTICLE INFO ______________________________________________________________ ______________________ Objective: To analyze patients from an underserved area who presented initially with Key words: metastatic prostate cancer in order to identify patients in our population who would Prostatic Neoplasms; suffer greatly if PSA screening was eliminated. Prostate-Specific Antigen; Materials and Methods: A prospectively maintained androgen deprivation therapy da- Mass Screening; Medically tabase from an inner city municipal hospital was queried to identify patients who Underserved Area presented with metastatic prostate cancer. We identified 129 individuals from 1999 to 2009 eligible for study. Those who underwent previous treatment for prostate cancer Int Braz J Urol. 2014; 40: 316-21 were excluded. We examined metastatic distribution and analyzed survival using Ka- plan Meier probability curves. Results: The median age of presentation was 68 with a median Gleason sum of 8 _____________________ per prostate biopsy. Thirty-two patients presented with hydronephrosis with a median Submitted for publication: creatinine of 1.79, two of whom required emergent dialysis. Of those patients who August 13, 2013 underwent radiographic imaging at presentation, 35.5% (33/93) had lymphadenopathy suspicious for metastasis, 16.1% (15/93) had masses suspicious for visceral metastases. _____________________ Of the patients who underwent a bone scan 93% (118/127) had positive findings with Accepted after revision: 7.9% (10/127) exhibiting signs of cord compression. The 2 and 5- year cancer specific March 22, 2014 survival was 92.1% and 65.6%, respectively. Conclusions: In this study we have highlighted a group of men in an underserved com- munity who presented with aggressive and morbid PCa despite widespread acceptance of PSA screening. INTRODUCTION monstrated a decrease in metastatic disease from 77 per 100,000 patients in1990 to 37 per 100,000 Prostate cancer (PCa) remains among the patients in 2000 (3). most common causes of cancer related deaths in Despite an overall trend towards organ North American men with an estimated 28,170 confined, lower risk disease, the incidence and deaths in 2012 (1). Since the inception of PSA mortality rates of PCa in men of lower socioeco- screening in the early 1980’s, a stage and grade nomic status (SES) and African American race has migration towards diagnosing lower risk PCa has remained disproportionately high and relatively been identified. With this stage migration it was unchanged throughout the PSA screening era. A observed a lower incidence of metastatic disease retrospective study looking at low income, unin- and improved mortality rates (2). Etzioni et al. de- sured men in California suggested that despite 316
IBJU | A 10-YEAR ANALYSIS OF METASTATIC PROSTATE CANCER widespread use of PSA screening, clinical T sta- such as percentage of PCa within fragment; we ge, Gleason scores, and rates of metastatic disease simply get a Gleason score. Also, many of the remained unchanged over time (4). Another study biopsies performed for men with mPCa upon pre- from Brazil investigated the impact of screening sentation included only one or two cores in order for PCa versus traditional referral for cancer tre- to get a tissue diagnosis prior to starting systemic atment on clinical and pathological features, and therapy. Therefore, all we have to report is the found that cancers detected through screening Gleason score, which is mentioned in the results proved to be significantly more favorable (5). section below. Race also appears to contribute to the dis- All patients were treated with androgen proportionate rates of incidence and mortality of deprivation initially with an androgen receptor PCa. Jemal et al. demonstrated that over a 5-year blocker or ketoconazole for several weeks, which span African American men were 1.5 times more was given at the discretion of the treating physi- likely to be diagnosed with PCa and 2.4 times more cian. Following initial treatment, all patients were likely to die from the disease than white men (6). placed on an LHRH agonist. Biochemical failure Considering recent controversies regarding was defined as a rise in serum PSA from nadir PSA screening, we sought to identify patients in levels with a castrate testosterone level less than an underserved population who presented initially 50ng/mL. Individuals with evidence of bioche- with metastatic prostate cancer (mPCa) to identify mical failure were referred to medical oncology who would suffer if PSA screening was eliminated. for initiation of secondary treatment. Secondary treatment was administered at the discretion of MATERIAL AND METHODS the treating medical oncologist. Using SPSS 17.0 we constructed Kaplan After obtaining Institutional Review Board Meier probability curves for overall survival and approval we queried a prospectively maintained cancer specific survival. androgen deprivation therapy database from an inner city municipal hospital to identify patients RESULTS who at initial presentation were found to have a diagnosis of mPCa. All patients in our study had a Our patient population was predominan- prostate biopsy confirming the presence of cancer. tly African American (N = 126) with only two mPCa was confirmed with either a bone scan that Hispanic and one Middle Eastern patient in our was positive for disease or a CT scan with eviden- cohort. The median age at presentation was 68 ce of visceral metastasis. Imaging was also used years (IQR 63,75) with a median total Gleason to evaluate lymph node status. A board certified sum of 8 (IQR 7.75,9). The median PSA level at Radiologist reviewed all images. presentation was 275ng/mL (IQR 132,88). The We identified 202 individuals from 1999 median creatinine level and hematocrit were to 2009 with mPCa. Patients who had imaging 1.2mg/dL (IQR 1,1.6) and 37.9 (IQR 32.2,41.4), studies performed within 30 days of PCa diagno- respectively (Table-1). The median follow-up was sis were included in our study. Individuals who 26.6 months. The patients in this cohort presen- were previously treated for PCa were excluded. ted over the course of 10 years (1999-2009), ho- One hundred and twenty nine patients met our wever our median follow-up time for these indi- inclusion criteria and were included in our study. viduals was only 26.6 months. We examined median age at diagnosis, Thirty-two patients presented with hydro- Gleason score, PSA, creatinine level, hematocrit nephrosis with a median creatinine of 1.79ng/dL and the need for hemodialysis at the time of pre- (IQR 1.04, 4.12), two of whom required emergent sentation. We examined the metastatic distribu- dialysis. Thirteen of the 32 patients (40.6%) who tion in our patient population using nuclear bone presented with hydronephrosis required inter- imaging and CT scans. Unfortunately, the repor- vention with either a percutaneous nephrostomy ting system at our hospital does not give details tube or ureteral stent placement. Intervention 317
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