PATTERNS-OF-FAILURE ANALYSIS OF PATIENTS WITH HIGH PRETREATMENT PROSTATE-SPECIFIC ANTIGEN LEVELS TREATED BY RADIATION-THERAPY - THE NEED FOR IMPROVED SYSTEMIC AND LOCOREGIONAL TREATMENT

Purpose: The patterns of failure (local and/or regional v metastatic) have been determined for patients with prostate cancer and pretreatmen t prostate-specific antigen (PSA) levels greater than or equal to 20 n g/mL treated with radiation alone with the purpose to design appropria te multimodal treatments. Materials and Methods: One hundred twenty pa tients with pretreatment PSA levels greater than or equal to 20 ng/mL were treated with external-beam radiation alone between February 1988 and October 1993. They were arbitrarily divided by PSA levels, 20 to 2 9.9 ng/mL, 30 to 49.9 ng/ mL, and greater than or equal to 50 ng/mL, a nd analyzed in terms of freedom from any failure (no evidence of bioch emical disease [bNED], and PSA level < 1.5 ngm/mL and not increasing), as well as freedom from imaging evidence of distant metastasis (fdm). Results: There was no significant difference in shortterm outcome by pretreatment PSA level, and thus all patients were pooled for analysis . At 4 years, 81% were fdm and 28% were free of any failure. This sugg ests that approximately 50% have recurred with local and/or regional d isease or undetectable metastatic disease. Multivariate analysis indic ated that low palpation stage and higher center of prostate dose were associated with better bNED survival. Multivariate analysis indicated that increasing stage and younger age are significantly associated wit h increasing distant metastasis. Conclusion: patients with pretreatmen t PSA levels greater than or equal to 20 ng/mL are not optimally treat ed by irradiation alone. The pattern of failure suggests improvement m ay come from systemic treatment of metastatic disease and high-dose ra diation to improve locoregional disease. To evaluate this, we have beg un a multimodal trial of chemohormonal therapy followed by extended-fi eld irradiation. (C) 1996 by American Society of Clinical Oncology.