- Reduction of the tumor mass may improve cancer control and increase the effect of systemic therapy
- It may reduce the shedding of metastatic cells from the primary tumor
- It could reduce the paraneoplastic effect by the primary tumor
- Possible reduction of the immunosuppressive effect caused by the primary tumor
Figure 1 – Failure-free survival in the radiotherapy + hormonal arm compared to the hormonal only arm:
Another study analyzed the role of local therapy (either radical prostatectomy[RP] or radiotherapy [RT]) in node-positive patients2. This study assessed 2967 patients who received surgery with hormonal therapy versus patients who received hormonal therapy alone for positive node disease. It was shown that local therapy + hormonal treatment was associated with significant overall mortality (OM) free survival benefit when compared with patients who received hormonal only therapy. At five years, OM-free survival was 78.8% vs. 49.2% in the local therapy + hormonal therapy arm vs. the hormonal therapy only arm, respectively. No significant difference was demonstrated when comparing RP + hormonal therapy to RT + hormonal therapy.
Unfortunately, to date, there is no level one evidence studies on the role of RP in metastatic patients. However, there are several retrospective studies, mainly from large population-based databases, showing an overall benefit (Table 1). One study has shown that the greatest impact of RP is in metastatic prostate cancer patients who have a predicted risk of cancer-specific mortality of less than 50%3 (Figure 2). Other studies have shown a 72-73% reduction in OM and cancer-specific mortality (CSM) in patients treated with RP compared to those who were not. However, these optimistic results cannot replace a randomized controlled study.
Table 1 – Retrospective studies are assessing the role of radical prostatectomy in metastatic prostate cancer patients:
Figure 2 – Which metastatic prostate cancer patients benefit the most from radical prostatectomy?
When considering RP in these patients, it is important to remember that these cytoreductive procedures entail a great risk of complications and mortality and at a greater cost, when compared to standard RP4 (Table 2). Additionally, it is currently not clear whether this type of procedure improves the quality of life of these patients. The most recent EAU guidelines state that according to the evidence that we have today, local treatment in metastatic prostate cancer patients should only be used as part of a clinical trial. Fortunately, there are many ongoing clinical trials that will hopefully help us to better assess the role of local treatment in this setting within the next 12 months (Table 3).
In summary, there is a need to improve the treatment of metastatic prostate cancer patients, as mortality is still significant with existent current therapy. Although local treatment, including RP, might have a role, level 1 evidence currently does not exist. Hopefully, in the very near future answers will become available as prospective data will be published.
Table 2 – Comparison of perioperative outcomes between cytoreductive radical prostatectomy and radical prostatectomy for non-metastatic prostate cancer, demonstrating greater morbidity, and costs:
Table 3 – Ongoing prospective trials assessing the role of local therapy in metastatic prostate cancer patients:
Presented by: Nazareno Suardi, Milan, Italy
Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter:@GoldbergHanan at the EAU Robotic Urology Section (ERUS) Meeting - September 5 - 7, 2018 - Marseille, France
- James ND, Spears MR, Clarke NW, et al. Failure-Free Survival and Radiotherapy in Patients With Newly Diagnosed Nonmetastatic Prostate Cancer: Data From Patients in the Control Arm of the STAMPEDE Trial. JAMA oncology 2016; 2(3): 348-57.
- Seisen T, Vetterlein MW, Karabon P, et al. Efficacy of Local Treatment in Prostate Cancer Patients with Clinically Pelvic Lymph Node-positive Disease at Initial Diagnosis. European Urology 2017.
- Fossati N, Trinh QD, Sammon J, et al. Identifying optimal candidates for the local treatment of the primary tumor among patients diagnosed with metastatic prostate cancer: a SEER-based study. European urology 2015; 67(1): 3-6.
- Preisser F, Mazzone E, Nazzani S, et al. Comparison of Perioperative Outcomes Between Cytoreductive Radical Prostatectomy and Radical Prostatectomy for Nonmetastatic Prostate Cancer. European urology 2018.