What is the prognosis of metastatic and advanced prostate cancer?

Updated: Dec 29, 2020
  • Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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Answer

Despite the steady decline in the incidence of newly diagnosed metastatic prostate cancer and microscopic lymph node metastasis, the risk of extraprostatic disease in patients with clinically localized disease remains high (30-60%). Depending on the prostate-specific antigen (PSA) value, pathologic stage, and histologic grade of the tumor, approximately 50% of patients with clinically localized prostate cancer are estimated to progress despite initial treatment with intent to cure. The Partin tables are the best nomogram for predicting prostate cancer spread and prognosis.

Although a Gleason grade of 7 or less is associated with a better prognosis than a grade of 8 or more, if the PSA level rise occurs after 2 years following local treatment, the associated survival likelihood is greater than if the rise occurs before 2 years.

In a study on higher serum concentrations of C-reactive protein, Prins et al found that inflammation may have a crucial role in the natural history of advanced prostate cancer. C-reactive protein is a readily measurable biomarker with the potential to enhance prognostic models and should be validated in a prospective clinical trial. [57]

If given enough time, all patients with metastatic disease become resistant to androgen ablation. The median time to symptomatic progression after a rise in the PSA level of more than 4 ng/mL is approximately 6-8 months, with a median time to death of 12-18 months. Once the patient exhibits symptoms, the median survival is less than 1 year.

Elevated serum levels of markers of bone turnover may be prognostic for poor survival in castration-resistant prostate cancer. Lara and colleagues demonstrated the prognostic and predictive value of markers for bone resorption (N-telopeptide and pyridinoline) and formation (C-terminal collagen propeptide and bone alkaline phosphatase) in castration-resistant prostate cancer patients treated in a placebo-controlled phase III trial of docetaxel with or without the bone targeted endothelin-A receptor antagonist atrasentan (SWOG S0421). [58]

Elevated baseline levels of each of the markers were associated with worse survival (P < 0.001), and increasing marker levels by week 9 of therapy were also associated with subsequent poor survival (P < 0.001). Patients with the highest marker levels (upper 25th percentile) not only had a poor prognosis (hazard ratio, 4.3) but also had a survival benefit from atrasentan. [58]


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