Radical prostatectomy for locally advanced prostate cancer, which generally results in better outcomes than radiation therapy alone, is not often offered. But a 15-year survival rate of 80%—better than for radiation therapy, and equivalent to stage 2 surgery results—was achieved in men with clinical T3 disease who had the procedure, according to results of a long-term study at the Mayo Clinic, Rochester, Minn.
Many men with clinical T3 disease are told they can't be helped by surgery and are often referred to the clinic for second opinions, senior investigator Horst Zincke, M.D., director of urooncologic surgery at the clinic, told FAMILY PRACTICE NEWS.
Principal investigator John Ward, M.D., now of the Naval Medical Center, Portsmouth, Va., along with Dr. Zincke and other colleagues, conducted a retrospective study of 5,652 men who had radical prostatectomy for confirmed prostate cancer from 1987 to 1997 (a period when prostate-specific antigen [PSA] testing came into use).
Of those, 15% (842) had the surgery for clinical stage T3. Median follow-up was 10.3 years. Survival was compared with men who had prostatectomy for stage 2 disease during the same period as well as with published results for radiation therapy (BJU Int. 2005;95:751–6).
Reports in the literature indicate a 79% survival at 5 years for T3 disease treated with radiation alone, Dr. Zincke said in the interview. And, he and his colleagues noted, studies have also shown that cancer can persist in 14%–91% of men given radiotherapy.
The Mayo study found that survival rates with surgery were 95% at 5 years, 90% at 10 years, and 79% at 15 years. During those same periods, 85%, 73%, and 67% of patients, respectively, were free of local or systemic disease recurrence after surgery.
Although 21% of T3 patients were given neoadjuvant hormone therapy, that intervention had little impact on the grade, stage, or rates of margin positivity, and did not affect progression-free or cancer-specific survival, the authors said.
The fact that survival, complication, and incontinence rates were similar to those for surgery for T2 disease, including a 75% rate of erectile dysfunction, reflected “the infrequent use of a nerve-sparing technique,” the authors reported. Perioperative mortality was the same as for T2 patients.
Experts continue to debate T3 disease management, and surgery has declined significantly in the United States; only about 6% of T3 patients undergo radical prostatectomy, according to the authors. At the Mayo Clinic, the number of patients receiving the procedure has dropped from 25.3% of T3 patients in 1987 to 2.8% in 2001. The decline may partly be due to overstaging by PSA results—in this study, 27% were clinically overstaged, the authors said.
And surgeons have gotten more wary of operating when they believe the cancer is extracapsular, Dr. Zincke said.
While the Mayo results were good, they may not be repeated everywhere, he said. The best candidates are patients in their 40s to 60s who have early extracapsular disease, Dr. Zincke said. With those men, “we know we can take the cancer out without causing increased morbidity,” he said.