Research ArticleClinical Studies

Prognostic Value of Lower Tract Urinary Symptoms in Clinically Regional Lymph Node-positive Prostate Cancer

LEANDRO BLAS, KOSUKE IEIRI, MASAKI SHIOTA, SHOHEI NAGAKAWA, SHIGEHIRO TSUKAHARA, TAKASHI MATSUMOTO, EIJI KASHIWAGI, ARIO TAKEUCHI, JUNICHI INOKUCHI, KEN-ICHIRO SHIGA, AKIRA YOKOMIZO and MASATOSHI ETO
Anticancer Research November 2021, 41 (11) 5593-5598; DOI: https://doi.org/10.21873/anticanres.15373

Abstract

Background/Aim: To explore the prognostic value of lower urinary tract symptoms (LUTS) in patients with newly diagnosed regional lymph node-positive prostate cancer. Patients and Methods: The prognostic value of LUTS for progression-free (PFS) and overall (OS) survival, as well as the differential prognostic impact of radiotherapy by LUTS was investigated. Results: Univariate Cox-model analysis showed a statistically significantly increased hazard risk for PFS and OS for men with International Prostate Symptom Score (IPSS)≥19 and Overactive Bladder Symptom Score (OABSS) ≥8 at diagnosis. Patients with lower IPSS had a better PFS at 5 years (70.0% vs. 51.9%, p=0.027) and OS at 5 year (89.3% vs. 73.6%, p=0.016). Similarly, a lower OABSS was associated with greater PFS at 5 years (67.4% vs. 23.4%, p<0.001) and OS at 5 years (85.3% vs. 57.1%, p=0.012). Conclusion: IPSS and OABSS were prognostic for PFS and OS in patients with regional lymph node-metastatic prostate cancer.

Key Words:

Clinically regional lymph node-positive (cN1) nonmetastatic prostate cancer is found in about 1.3-15% of new diagnoses (1). Historically, the treatment for this stage was androgen-deprivation therapy (ADT). But recently, studies have suggested survival benefits in both progression-free survival (PFS) and overall survival (OS) by combining local radiotherapy with ADT (2, 3). Based on these studies, adding local radiotherapy to 2 or 3 years of ADT in this scenario is recommended by the European Association of Urology guidelines, National Comprehensive Cancer Network guidelines, and by most experts (4-6).

Before the prostate specific-antigen (PSA) era, most prostate cancer was diagnosed by a biopsy triggered by findings in a digital prostate examination, local symptoms, or metastatic symptoms, or as an incidental finding in prostate tissue (7, 8). Since the widespread use of PSA, the number of symptomatic presentations has decreased, and the majority of prostate cancer cases are detected without significant symptoms. Thus, many men are diagnosed with a low-grade disease which may be indolent and which leads to overdiagnosis and possible overtreatment. However, high-grade disease grows both locally and distantly as a natural evolution. Patients with locally advanced prostate cancer can have lower urinary tract symptoms (LUTS) due to tumor compression of the urethra, invasion of the sphincter, or of the neurovascular bundle (8). As far as we know, there is no study evaluating LUTS in cN1 prostate cancer. Therefore, we aimed to explore the prognostic value of LUTS in newly diagnosed cN1 prostate cancer.

Patients and Methods

Patients. We included patients newly diagnosed with nonmetastatic cN1 adenocarcinoma of the prostate between 2008 and 2017 at Kyushu University Hospital and Harasanshin Hospital (Fukuoka, Japan) (9). We excluded patients with recurrence after previous treatment. Before castration-resistant prostate cancer, no case received chemotherapy and androgen pathway inhibitors (including abiraterone, enzalutamide, and apalutamide). This study was approved by Kyushu University Institutional Review Board (2021-123) and Harasanshin Hospital Institutional Review Board (2021-11).

The patients’ background information and survival data were retrospectively obtained from medical records. Gleason score and clinical TNM stage were determined according to the 2005 International Society of Urological Pathology Consensus and the seventh edition of the Union for International Cancer Control classification, respectively (10, 11). A lymph node size larger than 10 mm assessed by computed tomography or magnetic resonance imaging was considered positive. The regional lymph nodes included for cN1 disease were the obturator, internal iliac, and external iliac regions. ADT was performed by bilateral orchiectomy, castration monotherapy, or combined androgen blockade with a first-generation non-steroidal anti-androgen. The decision of prescribing radiotherapy was made after discussion between the physician and patient. Radiotherapy was performed by external radiation to the whole pelvis (range=41.4-50.0 Gy) followed by a boost to the prostate (range=22.0-30.0 Gy). Forty-eight patients (51.6%) were treated with radiotherapy. Of them, 47 were treated in the pelvis and prostate, and one patient only in the prostate. Disease progression was assessed by biochemical and radiologic progression, defined according to the Response Evaluation Criteria in Solid Tumors (12). For LUTS evaluation, the International Prostate Symptom Score (IPSS) and the Overactive Bladder Symptom Score (OABSS) were used (13, 14). IPSS is an eight-item questionnaire, consisting of seven symptom questions and one quality of life (QoL) question, and OABSS is a four-item questionnaire.

Statistical analysis. Continuous variables are expressed as the median and interquartile range and were compared using the Mann– Whitney U-test. Frequencies are given as number and percentage and were compared using the chi-square test. PFS was defined as the time from initial hormone therapy during which there was no recurrence. OS was defined as the time from initial hormone therapy to death or last contact with the patient. Survival rates were estimated using the Kaplan–Meier method and compared between groups using the log-rank test. Associations between patient progression or death and clinicopathological characteristics were evaluated using the Cox proportional risk model. Differences in the prognostic impact of subgroups were investigated through interaction tests. All statistical analyses were performed with Stata v16 (College Station, TX, USA) (15, 16). All tests were two-sided, and a value of p<0.05 was considered significant.

Results

In all, we included 93 Japanese patients, the baseline characteristics are shown in Table I. The median follow-up was 54 months (interquartile range=36-83 months). Thirty-six patients (38.7%) experienced progression to castration-resistant prostate cancer, and 16 patients (17.2%) died, of whom 12 patients (12.9%) died due to their disease.

View this table:
Table I.

Patient background characteristics.

When background variables were compared by LUTS scores, patients with high OABSS (≥8) or high IPSS (≥19) presented a significantly higher frequency of Gleason score 9 or 10 and higher positive biopsy core rate (Table II). Moreover, patients with high IPSS presented a higher rate of high T-stage (T3b-4) at diagnosis and more positive nodes (Table II).

View this table:
Table II.

Comparison of patients’ background by scores for lower urinary tract symptoms.

Univariate Cox-model analysis showed a statistically significant increased risk for poorer PFS and OS for men with high IPSS at diagnosis (Table III). An increased risk for poor PFS and OS was shown for patients with high OABSS compared to low OABSS. On the other hand, the presence of LUTS or score ≥5 in the QoL question in IPSS did not show any statistical association with PFS or OS.

View this table:
Table III.

Association between lower urinary tract symptoms and prognosis.

The median PFS was 99 months [95% confidence intervaI (CI)=69-110 months]. The PFS rate at 5 years for patients with low and high IPSS were 70.0% (95% CI=53.4-83.4%) and 51.9% (95% CI=30.6-69.6%), respectively (Figure 1A; p=0.027). The median OS was 130 months (95% CI=100 months-not reached). The OS rate at 5 years was 89.3% (95% CI=75.6-95.6%) and 73.6% (95% CI=50.2-87.3%) for patients with low and high IPSS respectively (Figure 1A, p=0.016). Similarly, PFS rates at 5 years for patients with low and high OABSS were 67.4% (95% CI=51.1-79.6%) and 23.4% (95% CI=4.4-50.9%), respectively (Figure 1B, p<0.001). OS rates at 5 years were 85.3% (95% CI=71.5-92.8%) and 57.1% (95% CI, 20.3-82.1%) for patients with low and high OABSS respectively (Figure 1B, p=0.012).

Figure 1.
Figure 1.

Kaplan–Meier curves for progression-free survival (PFS, left) and overall survival (OS, right) stratified by International Prostate Symptom Score (IPSS) (A) and Overactive Bladder Symptom Score (OABSS) (B).

Finally, we analyzed the differential effects of radiotherapy on progression and death from any cause by LUTS. High IPSS [hazard ratio (HR)=0.32, 95% CI=0.11-0.94, p=0.039] and QoL score (HR=0.33, 95% CI=0.12-0.89, p=0.029) were associated with decreased risk of progression with radiotherapy (Table IV). Similarly, High IPSS (HR=0.11, 95% CI=0.013-0.91, p=0.041), QoL score (HR=0.19, 95% CI=0.040-0.92, p=0.039) and low OABSS (HR=0.10, 95% CI=0.012-0.87, p=0.038) were associated with reduced risk of any-cause mortality with radiotherapy (Table IV). However, the interaction test showed none of these variables were differentially associated with PFS or OS among patients treated or not with radiotherapy (Table IV).

View this table:
Table IV.

Association of radiotherapy with prognosis in sub-grouped patients stratified by lower urinary tract symptom score.

Discussion

This study showed that patients with low IPSS and low OABSS had a statistically significantly longer OS and PFS than patients with high IPSS or OABSS, respectively. In patients treated with radiation therapy, PFS and OS were longer when IPSS and QoL score were low. These results support the notion that patients with cN1 nonmetastatic prostate cancer with fewer LUTS may have a better prognosis.

Previous studies showed that biopsy Gleason score and T-stage were prognostic of disease progression (9, 17-19). Additionally, the positive biopsy core rate and the number of node metastases was a prognostic factor for OS in patients with cN1 disease treated with local radiotherapy and ADT (9). In this study, patients with high IPSS and high OABSS presented higher positive biopsy core rates and higher Gleason scores. A high IPSS was also observed in patients with advanced T-stage and an increased number of metastatic lymph nodes. These findings may explain the relationship of IPSS and OABSS with prognosis.

There is mixed evidence for an association between LUTS and prognosis in prostate cancer. On one hand, several authors have reported higher grade and stage among patients with LUTS (20-22). A study using the South Australia Prostate Cancer Clinical Outcomes Collaborative database compared patients newly diagnosed with prostate cancer due to LUTS and due to elevated PSA level (23). They found lower OS, disease-specific survival, and metastasis-free survival for men presenting with LUTS. However, PFS was similar among men undergoing curative therapy. Ta et al. found that patients with voiding symptoms at diagnoses presented lower overall survival and disease-specific survival than asymptomatic patients (20).

On the other hand, others have found no association or even reduced risk of advanced or high-grade disease (24-26). Borre et al. showed no association between LUTS and tumor characteristics or treatment outcome in patients undergoing radical prostatectomy (27). They also suggested a worse long-term prognosis in asymptomatic patients than in patients with LUTS. Martin et al. similarly suggested a lower risk of death in patients with LUTS. However, these studies were performed in patients with localized prostate cancer, not in those with cN1 nonmetastatic prostate cancer (24). To our knowledge, this is the first study that showed the prognostic value of LUTS in cN1 prostate cancer.

The present study had several limitations. This was a retrospective study with a small sample size. All patients included were Japanese, which may limit the application of findings. There was no record of prostate and tumor size. Moreover, the radiotherapy protocol differed by year and institution. The follow-up schedule was not protocoled, which might have caused variance in PFS.

Conclusion

In conclusion, this study showed that IPSS and OABSS were prognostic for PFS and OS in patients with newly diagnosed regional lymph node-metastatic prostate cancer. These findings suggested a novel aspect of the role of LUTS on prognosis in regionally advanced prostate cancer.

Footnotes

  • Authors’ Contributions

    LB and MS participated in the design of the study and drafting of the article and were responsible for completing the study. MS, KI, SN, ST, TM, EK, AT, JI, KS, AY and ME were responsible for the clinical work of the study and recording of data. LB and MS reviewed the article. All Authors read and approved the final draft.

  • Conflicts of Interest

    None declared.

  • Received August 22, 2021.
  • Revision received October 11, 2021.
  • Accepted October 12, 2021.

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Prognostic Value of Lower Tract Urinary Symptoms in Clinically Regional Lymph Node-positive Prostate Cancer
LEANDRO BLAS, KOSUKE IEIRI, MASAKI SHIOTA, SHOHEI NAGAKAWA, SHIGEHIRO TSUKAHARA, TAKASHI MATSUMOTO, EIJI KASHIWAGI, ARIO TAKEUCHI, JUNICHI INOKUCHI, KEN-ICHIRO SHIGA, AKIRA YOKOMIZO, MASATOSHI ETO
Anticancer Research Nov 2021, 41 (11) 5593-5598; DOI: 10.21873/anticanres.15373
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