Natural history of progression after PSA elevation following radical prostatectomy.

Pound CR,  The Johns Hopkins Medical Institutions  JAMA 1999 May 5;281(17):1591-7

A total of 1997 men undergoing radical prostatectomy, by a single surgeon, for clinically localized prostate cancer. None received neoadjuvant therapy, and none had received adjuvant hormonal therapy prior to documented distant metastases. The actuarial metastasis-free survival for all 1997 men was 82% at 15 years after surgery. Of the 1997 men, 315 (15%) developed biochemical PSA level elevation, 103 (34%) developed metastatic disease within the study period. The median actuarial time to metastases was 8 years from the time of PSA level elevation. Once men developed metastatic disease, the median actuarial time to death was 5 years.
The time to PSA relapse was as noted:  44.7% by 1-2 y , 77% by 3-5 years, 96% by 6-9 years and 4% relapsed at 10 years or later. Of those who relapsed (based on the PSA only) only 34% developed metastases, so at 5 years 63% were still free of metastases. Of those who developed metastases the 5 year survival was 43%. So all told even though the cure rate after surgery was 87%/10 years and 82%/15 years, the survival from prostate cancer was much higher (94%/10 y an 91%/15y.) The risk of developing metastases was higher if the Gleason score was high and the risk was worse if the PSA relapse occurred quickly (i.e. within 2 years of surgery.) The published an algorithm on the risk of developing metastases after a PSA relapse, the key points are noted below: