ASCO GU 2020: Best of Journals Prostate Cancer: Surgery

San Francisco, California (UroToday.com) Dr. Nicola Fossati, MD, FEBU, Urologist at Vita-Salute San Raffaele University, presented some of the most influential articles from the past year in the field of prostate cancer research from a urology perspective. He focused on five areas: pre-operative setting, salvage radical prostatectomy, staging after biochemical recurrence, and quality of life.


The first article focused on risk stratification in the pre-operative setting.1 The aim of this study was to compare pre-treatment risk stratification tools for prostate cancer death in a retrospective cohort study of 154,811 men. The strengths of this study are large patient numbers and events, though it is limited by incomplete information for some predictors.

The authors concluded that the best risk stratification tools were the MSKCC nomogram (C-index 0.81), CAPRA score (C-index 0.80), and CPG system (C-index 0.78).

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The second article focused on the impact of hospital caseload in the pre-operative setting.2 The aim of this study was to evaluate the association of faculty annual caseload with overall survival (OS) in 488,389 men. The strengths of this study are large patient numbers and events, though it is limited by the potential for selection bias given the retrospective nature of the study. Patients were grouped into four groups from the lowest to highest caseload and surgical caseload hospital at which they were treated. Compared to those in the highest caseload group, those in the lowest caseload group had significantly worse OS (hazard ratio [HR] = 1.30; OS benefit of 13 months). Similar results were observed for annual surgical caseload (HR = 1.25; OS benefit of 11 months). This research supports the regionalization of radical prostatectomy to high-volume centers.

Dr. Fossati then discussed a study that aimed to report outcomes from a large series of salvage radical prostatectomy (RP) after focal therapy.3 The study population was 82 patients who underwent RP after focal therapy (FT) between 2010 and 2018. Initial focal therapy included HIFU (70%), cryotherapy (19%), electroporation (5%), VTPT (4%), and PRX302 (2%). RP complication rates post-FT were similar to those observed with upfront RP. Pathology revealed in-field recurrence in 23%, out of field recurrence in 26%, and both in 51%. Progression-free survival rates following RP were 74% at 1 year, 48% at 2 years, and 36% at 3 years, worse than would be expected based on clinical characteristics. Urinary continence was 83% and erectile function was 14% at 12 months post-RP. The results are retrospective with a non-comparative design, however, it represents the largest series of patients treated with salvage RP after FT.

The next study discussed was a prospective, single-center, single-arm comparative study of 18F-fluciclovine PET/CT and 68Ga-PSMA-11-PET/CT in 50 patients with biochemical recurrence after RP with PSA levels ranging from 0.2 to 2.0.4 Median PSA was 0.48 with PSA doubling time of 4 months. Detection rates were significantly higher for PSMA PET than fluciclovine PET in the overall cohort as well as in the prostate bed, pelvic lymph nodes, extra-pelvic lymph nodes, bone, and other organs. Of note, there was no histologic correlation in this study.

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The final study was a prospective, population-based cohort study (SEER Program) aimed at comparing functional outcomes associated with prostate cancer treatment over 5 years after treatment in 2,000 men with localized prostate cancer.5 Of 1,386 men with favorable-risk disease, 675 underwent RP, 363 went on active surveillance (AS), 261 received radiotherapy (RT), and 87 received brachytherapy. Of 619 men with unfavorable-risk disease, 402 underwent RP and 217 received RT. In favorable-risk patients, RP was associated with a significant impact on sexual function in the first year that resolves in the long-term. In unfavorable-risk patients, RP and RT are associated with similar rates of early sexual dysfunction and similar improvement over time. In both favorable- and unfavorable-risk disease, RP was associated with an increased risk of urinary incontinence compared to other treatment modalities that persisted after 5 years of follow-up. Given that 5-year cancer-specific survival is close to 100% for men with localized prostate cancer, these functional outcome and quality of life data are equally important outcomes of interest.

Presented by: Nicola Fossati, MD, FEBU, Urologist at Vita-Salute San Raffaele University

Written by: Jacob Berchuck, MD, Medical Oncology Fellow at the Dana-Farber Cancer Institute (Twitter: @jberchuck) at the 2020 Genitourinary Cancers Symposium, ASCO GU #GU20, February 13-15, 2020, San Francisco, California

References:

  1. Zelic R, et al. Predicting Prostate Cancer Death with Different Pretreatment Risk Stratification Tools: A Head-to-head Comparison in a Nationwide Cohort Study. Eur Urol. 2020 Feb;77(2):180-188.
  2. Barzi A, et al. Influence of the facility caseload on the subsequent survival of men with localized prostate cancer undergoing radical prostatectomy. Cancer. 2019 Nov 1;125(21):3853-3863.
  3. Marconi L, et al. Robot-assisted Radical Prostatectomy After Focal Therapy: Oncological, Functional Outcomes and Predictors of Recurrence. Eur Urol. 2019 Jul;76(1):27-30.
  4. Calais J, et al. 18F-fluciclovine PET-CT and 68Ga-PSMA-11 PET-CT in patients with early biochemical recurrence after prostatectomy: a prospective, single-centre, single-arm, comparative imaging trial. Lancet Oncol. 2019 Sep;20(9):1286-1294.
  5. Hoffman KE, et al. Patient-Reported Outcomes Through 5 Years for Active Surveillance, Surgery, Brachytherapy, or External Beam Radiation With or Without Androgen Deprivation Therapy for Localized Prostate Cancer. JAMA. 2020 Jan 14;323(2):149-163.
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