title: Conditional cancer-specific mortality in T4, N1, or M1 prostate cancer: implications for long-term prognosis.
abstract: BACKGROUND
  The risk of prostate cancer-specific mortality (PCSM) following a diagnosis of prostate cancer may improve after patients have survived a number of years after diagnosis. We sought to determine long-term conditional PCSM for patients with stage T4, N1, or M1 prostate cancer.
  
  
  METHODS
  We identified 66,817 patients diagnosed with stage IV (T4N0M0, N1M0, or M1) prostate cancer between 1973 and 2011 using the Surveillance, Epidemiology, and End Results (SEER) database. Conditional five-year PCSM was evaluated for each group of patients at 5, 10, and 15 years of survival according to the Fine & Gray model for competing risks after adjusting for tumor grade, age, income level, and marital status. Race-stratified analyses were also performed.
  
  
  RESULTS
  There were 13,345 patients with T4 disease, 12,450 patients with N1 disease, and 41,022 patients with M1 disease. Median follow-up among survivors in the three groups was 123 months (range: 0-382 months), 61 months (range: 0-410 months), and 30 months (range: 0-370 months), respectively. Conditional PCSM improved in all three groups over time. Among patients with T4 disease, 5-year PCSM improved from 13.9% at diagnosis to 11.2, 8.1, and 6.5% conditioned on 5, 10, or 15 years of survival, respectively (p < 0.001 in all cases). In patients with N1 disease, 5-year PCSM increased within the first five years and decreased thereafter, from 18.9% at diagnosis to 21.4% (p < 0.001), 17.6% (p = 0.055), and 13.8% (p < 0.001), respectively. In patients with metastatic disease, 5-year PCSM improved from 57.2% at diagnosis to 41.1, 28.8, and 20.8%, respectively (p < 0.001). White race was associated with a greater increase in conditional survival compared to non-white race among those with T4 or N1 disease.
  
  
  CONCLUSIONS
  While patients with T4, N1, or M1 prostate cancer are never "cured," their odds of cancer-specific survival increase substantially after they have survived for 5 or more years. Physicians who take care of patients with prostate cancer can use this data to guide follow-up decisions and to counsel newly diagnosed patients and survivors regarding their long-term prognosis.
authors.affiliation: Harvard-MIT Division of Health Sciences and Technology, Harvard Medical School, Boston, MA, 02115, USA. vinayak_muralidhar@hms.harvard.edu.
authors.forename: Vinayak
authors.initials: V
authors.lastname: Muralidhar
authors.affiliation: Harvard Medical School, Boston, MA, 02115, USA. bmahal@partners.org.
authors.forename: Brandon A
authors.initials: BA
authors.lastname: Mahal
authors.affiliation: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA. pnguyen@LROC.harvard.edu.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Nguyen
mesh_terms: D000368:Aged; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D011471:Prostatic Neoplasms / Q000401:mortality* / Q000473:pathology*; D018426:SEER Program; D016019:Survival Analysis