San Diego, CA USA (UroToday.com) In today’s Society of Urologic Oncology meeting at the 2016 AUA, Dr. James Efstathiou discussed the role of definitive local therapy for patients with clinically node-positive disease. In the 220,000 new cases of prostate cancer per year, approximately 12% are node positive, which is considered stage 4 disease. Treatment with ADT alone has been studied in EORTC 30846, and demonstrated a 10 year mortality of 55.6% in the delayed treatment group.
RT added to ADT improves survival in locally advanced prostate cancer, although this was identified in retrospective analyses only.
Lin and colleagues studied the NCDB for trends of treatment for all patients diagnosed with CN+ prostate cancer. In 3500 non-RP patients, they found that 50% receive hormone and radiation, and 33% receive hormones alone. Thus, half of patients with node positive disease are not getting definitive therapy with curative intent. On propensity weighted survival analysis, the investigators found a 50% decrease in risk of mortality with the addition of RT to hormones vs hormones alone. Subgroup analysis showed survival benefits were independent of age, stage, grade, and PSA. The Stampede trial further illustrated the benefit of RT in clinically node positive patients. Those receiving RT had 50% decrease in freedom from failure compared to non-RT patients.
Regarding surgery, RP is more commonly being done in high-risk disease patients. Many patients will ultimately need adjuvant ADT and RT, and selection of these patients can be facilitated with genomic testing. Those with node-positive disease can do well postoperatively depending on the nodal disease burden. Support for this comes from study of the Munich Cancer Registry, where patients who had prostatectomy abandoned had more positive nodes and higher PSA vs those who had prostatectomy performed. Aborted surgery was associated with 2x increased mortality.
Dr. Efstathiou concluded that node positive disease is common and is likely to increase in incidence. Definitive local therapy likely improves survival compared to ADT alone (i.e. RT or RP). Almost 50% of patients may be undertreated, and current practice guidelines should be reevaluated. Clinically node-positive disease is under-studied, and we need more RCTs to assess optimal treatment strategy.
Presented By: James Efstathiou, MD