A Framework for Treatment Decision Making at Prostate Cancer Recurrence

Area of Science:

• Urology
• Oncology
• Medical Decision Making

Background:

• Prostate cancer patients undergoing radical prostatectomy face a significant risk of prostate-specific antigen recurrence (PSA-R).
• Deciding on salvage therapy (ST) at PSA-R is challenging due to potential benefits in reducing metastasis versus risks of overtreatment and side effects.
• A novel harm-benefit framework was developed to aid shared decision-making for ST post-PSA-R.

Purpose of the Study:

• To develop and apply a quantitative harm-benefit framework for salvage therapy (ST) decisions following prostate-specific antigen recurrence (PSA-R).
• To estimate the impact of ST on metastasis risk and overtreatment rates in patients treated with radical prostatectomy.
• To inform shared decision-making between patients and physicians regarding ST after PSA-R.

Main Methods:

• Analysis of 1,045 Johns Hopkins University Hospital patients with PSA-R post-radical prostatectomy (1984-2013).
• Utilized marginal structural models to estimate metastasis risk and ST effects, accounting for selection bias based on PSA growth.
• Developed a model to predict harm-benefit tradeoffs of ST, defining benefit as reduced metastasis risk and harm as overtreatment.

Main Results:

• Salvage therapy (ST) was associated with a 0.41 adjusted hazard ratio for metastasis.
• Treating all men at PSA-R reduced metastasis risk from 43% to 23% but resulted in 31% overtreatment.
• ST for men with Gleason score >7 reduced metastasis risk from 67% to 39% with only 13% overtreatment.

Conclusions:

• A quantitative framework evaluating ST harms and benefits aids decision-making after PSA-R.
• Immediate ST may be more appropriate for specific patient subgroups identified as having an elevated risk of metastasis.
• The framework supports personalized treatment strategies balancing metastasis prevention with avoiding unnecessary overtreatment.