Dr. Joniau notes that the natural history of non-curatively treated, high-risk prostate cancer is often prostate-cancer-specific mortality. Indeed, even in elderly patients >75 years of age, 35-40% of patients with non-curative treatment for high-risk disease will suffer disease-specific mortality. According to Dr. Joniau, there are several advantages that surgery offers:
- Improved survival over observation or ADT alone
- Single-modality treatment in selected patients
- A minimally invasive approach, such as robotic prostatectomy
- Satisfactory function and quality of life outcome
Data from a study in 20082 assessing oncological outcomes in high-risk prostate cancer patients undergoing surgery suggest there is a substantial portion of patients that will be free from additional therapy and prostate cancer outcomes 10-years after radical prostatectomy. 10-year free from:
- Radiation therapy: 74-86%
- ADT: 41-82%
- Radiation therapy or ADT: 35-76%
- Metastatic disease: 72-91%
- Prostate cancer-specific mortality: 88-97%
Certainly, high-risk surgery has several disadvantages considering it is more aggressive than surgery for low/intermediate-risk prostate cancer, notably: (i) higher risk of incontinence/ED, and (ii) higher complication rates (lymphedema, lymphocele). Surgery is often the first step in a multimodal approach, although there is no level 1 evidence as of yet. According to Dr. Joniau, there is a scale of aggressiveness for nerve sparing, depending on the D’Amico risk stratification of the patient (neurovascular bundle preservation is possible in >50% of cases in high-risk patients):
Importantly, patients who receive a radical prostatectomy + radiation therapy have a 4% overall and 1% higher severe incontinence at 3 years compared to patients treated with radical prostatectomy alone. ADT further increases overall and severe incontinence rates. Adding radiation therapy to radical prostatectomy is associated with an 18% lower rate of potency after treatment compared to radical prostatectomy alone; the addition of ADT further reduces potency rates by another 17%.
Dr. Joniau concluded with several important points making the argument for surgery in high-risk patients:
- Properly performed, radical prostatectomy is a highly effective treatment for high-risk and locally advanced prostate cancer in men with a sufficiently long-life expectancy to justify the risks
- Surgery leads to a good OS and excellent CSS
- Monotherapy may be possible in ~50% of cases
- Surgeons should preserve nerves whenever safe and feasible; 25-30% of men may gain back their erectile function
- Return of continence is in the range of ~80% at the time of 1-year
- Adjuvant RT +/- ADT has a major impact on ED and continence recovery
- Treatment of the primary allows for optimal local control, avoiding LUTS and late local complications
Presented by: Presented by: Steven Joniau, MD, Ph.D., Department of Urology, Development, and Regeneration, Universitair Ziekenhuis, Leuven, Belgium
Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic
- Fossa SD, Nilssen Y, Kvale R, et al. Treatment and 5-year survival in patients with nonmetastatic prostate cancer: the Norwegian experience. Urology 2014 Jan;83(1):146-152.
- Yossepowitch O, Eggener SE, Serio AM, et al. Secondary therapy, metastatic progression, and cancer-specific mortality in men with clinically high-risk prostate cancer treated with radical prostatectomy. Eur Urol 2008 May;53(5):950-959.
- Joniau S, Briganti A, Gontero P, et al. Stratification of high-risk prostate cancer into prognostic categories: a European multi-institutional study. Eur Urol 2015 Jan;67(1):157-164.
What is High Quality Local Treatment in High Risk Localized Prostate Cancer? Radiotherapy