Declining rates of extracapsular extension after radical prostatectomy: Evidence for continued stage migration

Purpose: Prostate-specific antigen (PSA)-based screening is responsible for a profound clinical stage migration in newly defected prostate cancers. Ex tracapsular extension (ECE) is an important predictor of outcome after radi cal prostatectomy (RP). We examined trends in the rate of ECE for cancers d etected by PSA screening in 731 RP specimens between 1987 and 1997, when sc reening became routine urologic practice in the United States. Methods: The rates of ECE were examined in 311 prostates with nonpalpable ( stage T1c) disease and 420 with palpable but clinically localized (stage T2 ) disease. Specimens were step sectioned and examined by a senior pathologi st. Rates of ECE were compared with respect to time, and logistic regressio n was used to identify predictors of ECE. Results: The rate of ECE decreased from 81% to 36% during the 10-year obser vation period. Multivariate analysis involving clinical tumor stage, preope rative serum PSA level, and Gleason score demonstrated that year of treatme nt was an independent predictor of ECE, with a two-fold reduction of risk o ccurring during the study period (P <.001; odds ratio, 1.96; 95% confidence interval, 1.37 to 2.78). Conclusion: PSA screening has resulted in a downward trend in pathologic st age in clinically localized prostate cancer, independent of preoperative PS A level, tumor stage, and Gleason score. This time-dependent downward stage migration suggests the need for continuous updating of predictive nomogram s and caution in interpreting differences in contemporarily treated patient s compared with historical controls. Further study is needed to determine w hether this trend will translate into improved disease-free survival. (C) 1 999 by American Society of Clinical Oncology.