MADRID, SPAIN (UroToday.com) - Dr. Francesco Montorsi presented this important topic of true morbidity of multimodality treatment. He emphasized that he did not want to discuss whether radiotherapy is better than surgery, but rather the risks of current multimodal treatment. "I don’t want to discuss concept A is better than B but want to share the reality of fact that multimodal treatment is needed.”
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He stated, “as urologists treating patients with prostate cancer, we should know the complications and risks of our own procedure. If we don’t know the complications of our treatments, we should be ashamed.” He encouraged urologists to first define complications, preferentially use a standardized system such as the Clavien-Dindo grading system, and improve reporting of complications.
From the San Raffaele experience, there are 12% complication rates after radical prostatectomies. The addition of extended lymphadenectomy increases the risk of post-operative complications 1.7 fold (Briganti et al., EAU 2014). Additionally, there are long-term functional implications of treatment of localized prostate cancer (Resnick NEJM). Both prostatectomy and radiation therapy are associated with lower sexual function and urinary function even up to 15 years after primary treatment. For high-risk patients, urinary continence recovery and erectile function recovery is worse compared to low- and intermediate-risk patients (Gandaglia, J Endourol 2014).
A Cochrane database systemic review on the role of adjuvant therapy vs observation following radical prostatectomy suggests that urinary continence and urethral stricture rates are worse after adjuvant therapy (Daly et al. 2011). Patients treated with adjuvant radiation therapy have 1.6-fold higher risk of incontinence (Suardi et al., Eur Urol 2014). Additionally, hypofractionated adjuvant RT compared to conventional RT has 2.79-fold increase in late Grade 3-4 urinary toxicities (Cozzanini et al., Eur Urol, 2014) and the detrimental effects of these are unacceptable.
In the literature, there is no clear information about the adverse effects of ADT in the context of multimodal treatment (surgery + ADT). However, whenever ADT is used, one should consider use of intracavernosal injections for ED as PDE5 are useless.
Dr. Montorsi concluded that the risk of short- and long-term side effects after multimodal treatment is not negligible among prostate cancer patients. Nevertheless, the harms of a multimodal approach should not preclude its adoption when clinically indicated as survival may be compromised if it is precluded. Baseline patient characteristics and the type of treatment planned may help clinicians in the identification of individuals at high risk of morbidity. Finally, accurate patient selection is mandatory in order to reduce the risk of short- and long-term adverse events associated with the treatment.
Presented by Francesco Montorsi at the 30th Annual European Association of Urology (EAU) Congress - March 20 - 24, 2015 - IFEMA - Feria de Madrid - Madrid, Spain
University Vita-Salute San Raffaele in Milan, Italy
Reported by Mohammed Haseebuddin, MD, medical writer for UroToday.com