MADRID, SPAIN (UroToday.com) - In this portion of the discussion addressing the questions of whether surgery or radiotherapy is preferred in the treatment of patients with high-risk prostate cancer, Dr. Markus Graefen presented the case for radical prostatectomy (RP).
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He began by pointing out that RP in high-risk patients is effective as a single therapy, with up to 50% of patients not requiring a secondary therapy according to results of the IMPACT trial. Radiation therapy for high-risk prostate cancer, in contrast, requires the use of concurrent androgen deprivation therapy (ADT) for an extended period of time, which significantly impacts on patient quality-of-life (QOL). Dr. Graefen presented data from his own institution regarding the need for secondary therapies after RP in high-risk patients. He stressed the need to counsel patients about the possibility of the need for multimodal therapy, but also pointed out that, at their institution, two-thirds of patients did not require either adjuvant or salvage radiation or hormone therapy at 3 years after RP.
One of the significant advantages of RP was the ability to more definitively stage a patient’s disease allowing for more effective tailoring of treatment. He went back to the IMPACT trial to point out that of patients who had clinically high-risk disease, 44% had organ-confined cancer. This not only has significant treatment implications but also potentially impacts the patient’s psychological well-being for the better.
Dr. Graefen then addressed surgical considerations in patients with high-risk disease. He noted that urinary continence rates are no different following RP for patients with high-risk disease when compared to low- or intermediate-risk disease. He highlighted the use of MRI in these patients for disease localization and assessment of extracapsular extension to aid in surgical planning and allow for nerve sparing where possible. He also discussed how the use of frozen sections to achieve close but negative margins ensures that nerve sparing is accomplished when possible. Using these techniques, he stated that nerve-sparing—either unilateral or bilateral—could be accomplished in up to two-thirds of patients with high-risk disease, a significant proportion of whom will maintain potency.
He finished his argument by presenting a population-based study by Nam, et al. which looked at 30 000 patients treated with RP or radiation therapy and found that “after accounting for age, comorbidity, and year of treatment using direct matching and propensity score analysis, radiotherapy was associated with a significantly higher risk of complications in all 5 categories assessed compared to surgery.” The complication categories included minimally invasive procedures (e.g., cystoscopy), hospital admission, rectal/anal procedures, secondary malignancy, and open surgical procedures.
Dr. Graefen concluded his talk by pointing out that assessment of relative efficacy in the future will require the usage of standardized patient-related outcome measurements which are used to assess patients both at baseline and post-treatment. He emphasized the need for these measures to be used across all treatment options in order for appropriate and accurate comparisons to be made.
Presented by Markus Graefen at the 30th Annual European Association of Urology (EAU) Congress - March 20 - 24, 2015 - IFEMA - Feria de Madrid - Madrid, Spain
University Medical Center Hamburg-Eppendorf
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Reported by Timothy Ito, MD, medical writer for UroToday.com