title: Long-term cancer control outcomes in patients with clinically high-risk prostate cancer treated with robot-assisted radical prostatectomy: results from a multi-institutional study of 1100 patients.
abstract: BACKGROUND
  Long-term cancer control outcomes in clinically high-risk prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy (RARP) remain unknown.
  
  
  OBJECTIVE
  To report on long-term biochemical recurrence (BCR)-free survival, clinical recurrence (CR)-free survival, and salvage therapy rates in these patients. Given the heterogeneity of high-risk patients, a second objective was to stratify them according to their BCR risk (using preoperative parameters), in an effort to counsel them better preoperatively regarding their cancer control outcomes.
  
  
  METHODS
  We evaluated 1100 D'Amico high-risk PCa patients who underwent RARP between 2002 and 2013 at three tertiary care centers.
  Outcomes consisted of BCR-free survival, CR-free survival, and salvage therapy rates. Regression tree analysis stratified patients into novel risk groups based on preoperative characteristics and corresponding BCR risk. Kaplan-Meier curves estimated BCR-free survival, CR-free survival, and salvage therapy rates in the entire cohort and after stratification according to the novel risk groups (RGs).
  
  
  CONCLUSIONS
  Median age and prostate-specific antigen (PSA) were 63 yr and 6.5 ng/ml, respectively. Biopsy Gleason score (GS) was ≥8 in 57.7%. Mean follow-up was 53 mo (median: 49 mo). At 10 yr, BCR-free survival, CR-free survival, and salvage therapy rates were 50%, 87%, and 37%, respectively. Regression tree analysis stratified patients into five novel RGs): RG1, very low risk (GS ≤6); RG2, low risk (PSA ≤10 ng/ml; GS: 7); RG3, intermediate risk (PSA ≤10 ng/ml; GS ≥8); RG4, high risk (PSA >10 ng/ml; GS: 7); RG5, very high risk (PSA >10 ng/ml; GS ≥8). In these RGs, the 10-yr BCR-free survival rates were 86%, 70%, 36%, 31%, and 26% (p<0.001), respectively; the 10-yr CR-free survival rates were 99%, 96%, 85%, 67%, and 55% (p<0.001), respectively; and the 10-yr salvage therapy rates were 9.8%, 16%, 42%, 47%, and 64% (p<0.001), respectively.
  
  
  CONCLUSIONS
  Most patients with clinically high-risk PCa treated with RARP alone remain CR free at long term. Nonetheless, almost 37% of the patients at 10 yr require salvage therapy. Our novel tool allows accurate stratification of these heterogeneous patients according to their BCR, CR, and salvage therapy risks. This may help inform patients preoperatively about their cancer control outcomes postoperatively.
  
  
  RESULTS
  Robot-assisted radical prostatectomy confers lasting long-term oncologic control in most high-risk prostate cancer patients. Our novel risk grouping might serve as a useful tool for setting expectations and counseling patients regarding their cancer control outcomes.
authors.affiliation: Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA. Electronic address: firas.abdollah@gmail.com.
authors.forename: Firas
authors.initials: F
authors.lastname: Abdollah
authors.affiliation: Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Akshay
authors.initials: A
authors.lastname: Sood
authors.affiliation: Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Sammon
authors.affiliation: Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Linda
authors.initials: L
authors.lastname: Hsu
authors.affiliation: Martini Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Burkhard
authors.initials: B
authors.lastname: Beyer
authors.affiliation: Department of Urology, Vita Salute San Raffaele University, Milan, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Moschini
authors.affiliation: Department of Urology, Vita Salute San Raffaele University, Milan, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Gandaglia
authors.affiliation: Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Craig G
authors.initials: CG
authors.lastname: Rogers
authors.affiliation: Martini Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Haese
authors.affiliation: Department of Urology, Vita Salute San Raffaele University, Milan, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.affiliation: Martini Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Graefen
authors.affiliation: Department of Urology, Vita Salute San Raffaele University, Milan, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Briganti
authors.affiliation: Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Mani
authors.initials: M
authors.lastname: Menon
mesh_terms: D000368:Aged; D018572:Disease-Free Survival; D006801:Humans; D007610:Kallikreins / Q000097:blood*; D053208:Kaplan-Meier Estimate; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D017430:Prostate-Specific Antigen / Q000097:blood*; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000097:blood / Q000473:pathology / Q000601:surgery*; D012044:Regression Analysis; D065287:Robotic Surgical Procedures; D016879:Salvage Therapy / Q000706:statistics & numerical data; D016896:Treatment Outcome
chemical_list: C549870:KLK3 protein, human; D007610:Kallikreins; D017430:Prostate-Specific Antigen
keywords: Biochemical recurrence; Clinical recurrence; High risk; Metastasis; Prostate cancer; Robotics