IDENTIFICATION OF EARLY RECURRENCE AFTER RADICAL PROSTATECTOMY608

did Pound et al) but examined prostate cancer spe-cific mortality (references 4 and 6 in article). Herethe cut point of 3 years was analyzed rather than 2years based on the ability of the 3-year cutoff toseparate groups on univariate analysis. The 3-yearcutoff had a p �0.05 after forward stepwise variableselection, which was the argument for the value of ashort time to PSA recurrence. However, the univar-iate analysis for choosing the cut point and the for-ward stepwise variable selection method both resultin p values that are difficult to interpret. Thus, theevidence does not seem solid that early recurrence isassociated with future trouble after consideringother patient factors. In other words there are nostudies demonstrating the incremental predictivevalue of a short time to PSA recurrence.

At any rate urologists seem to want a 2-yearrecurrence prediction. Walz et al have done a fine jobof providing that tool. Their approach is solid andtheir tool appears to work well so far. The mostinteresting aspect of this study is in table 3. Thosevalues are plotted in the corresponding ROC curvewhich illustrates how silly it is to use an old schoolmethod (eg whether the patient has ECE) to predictthe likelihood of recurrence when you have a nomo-gram at your disposal (see figure). Resisting thenomogram in favor of using ECE to decide whoshould receive adjuvant therapy simply leads to mis-takes in both directions. You will unnecessarilytreat more patients plus fail to treat those who willultimately experience biochemical failure. Thus, re-lying on ECE is neither more conservative nor more

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rized as less than 3 years and more than 3 years, but

method, using ECE/SVI/Gleason to choose patients,only does as well as 1 particular nomogram cutoffpercentage. Walz et al should be congratulated forillustrating this in such a clear manner.

Michael W. Kattan

Cleveland Clinic Lerner College of Medicine ofCase Western Reserve University

Department of Quantitative Health SciencesCleveland Clinic

0.0 0.2 0.4 0.6 0.8 1.0

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1.0

False Positive Rate

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osi

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ECE

SVI

ECE+SVI

ECE+SVI+Glea son >=8

Plot of data in table 3 of article

aggressive, but simply more stupid. The best ad hoc Cleveland, Ohio

The definition of early recurrence as BCR within thefirst 2 years after RP might be considered arbitrary.However, it is based on the small number of analy-ses available to date addressing this topic (refer-ences 4 to 6 in article). In the analysis by Freedlandet al the cutoff of 3 years was identified by multiva-riable forward stepwise selection, and this cutoffremained an independent and significant predictorof time to prostate cancer specific death in the mul-tivariable Cox proportional hazard analysis includ-ing PSA doubling time and pathological Gleasonscore (reference 4 in article). Freedland et al alsoexplored the effect of early recurrence in more detailand showed that early recurrence is not only highlysignificantly associated with time to cancer specificdeath and faster PSA doubling time when catego-

also when used as a continuously coded variable(reference 6 in article).

In a multivariable analysis the risk of cancerspecific death decreased by 13% with every yearfrom surgery that passed without BCR. Therefore,it might be argued that the 2-year cutoff in ourstudy is based on an analysis difficult to interpretbut there is significant evidence that BCR earlyafter surgery has worse long-term outcome thanrecurrence later after surgery. In our opinionthese observations justify the approach of a pre-dictive tool for early recurrence after radical pros-tatectomy. However, the most informative cutoffof early recurrence may be at 2 years, 3 years orperhaps 18 months. Further research will be nec-essary to identify the optimal cutoff for early re-

currence.