Very high initial PSA levels in patients undergoing radical prostatectomy (RP) for high-risk clinically localized prostate cancer (PCa) are associated with worse oncologic outcomes, according to a new study.

Men with initial PSA levels of 50 ng/mL or higher have significantly worse rates of biochemical recurrence (BCR)-free survival, metastasis-free survival (MFS), and cancer-specific survival (CSS) compared with those who have preoperative PSA levels of 20 to 49.9 ng/mL.

The study included 2811 RP patients stratified according to preoperative PSA level: 20 to 49.9 (2195 patients), 50 to 99.9 (454 patients), and 100 ng/mL or higher (162 patients). All patients had negative findings on preoperative computed tomography and bone scintigraphy scans. During a median follow-up of 47.5 months, 1146 (40.8%), 297 (10.6%), and 119 (4.2%) patients experienced BCR, metastases, and death from PCa, respectively.

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Among patients in the 20 to 49.9, 50 to 99.9, and 100 ng/mL or higher PSA groups, the 10-year BCR-free survival rates were 46.9% vs 32.1% vs 29%, respectively, Derya Tilki, MD, of Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany, and colleagues reported in Urologic Oncology. The 10-year MFS rates were 78.4% vs 67.2% vs 37.3%, respectively. The 10-year CSS rates were 93.7% vs 85.5% vs 66.7%, respectively.

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On multivariable analysis, compared with the 20 to 49.9 ng/mL PSA category, the 50 to 99.9 and 100 ng/mL or higher categories were significantly associated with 1.3- and 1.4-fold increased risks of BCR, respectively, 1.4- and 2.3-fold increased risks of metastatic progression, respectively, and 1.9- and 3.4-fold increased risks of cancer-specific mortality, respectively.

The investigators concluded that men with initial PSA levels of 50 ng/mL or higher undergoing RP “may be counseled about a potentially increased risk of undetected metastases prior to RP possibly necessitating intensified multimodal treatments in the future.”

The study found that patients with higher initial PSA were younger and had more aggressive disease than their lower PSA counterparts.


Tilki D, Mandel P, Karakiewicz PI, et al. The impact of very high initial PSA on oncological outcomes after radical prostatectomy for clinically localized prostate cancer [published online January 27, 2020]. Urol Oncol.  doi: 10.1016/j.urolonc.2019.12.027