SAN ANTONIO — A large retrospective study with patients from the Mayo Clinic has demonstrated the advantages of radical prostatectomy in men with clinically advanced prostate cancer, John F. Ward, M.D., said at the annual meeting of the American Urological Association.
Most institutions refer such patients to radiotherapy, but the Mayo Clinic has long advocated surgery, even for prostate cancers that appear to have spread locally, Dr. Ward said at a press briefing. Nationwide, only 15% of men with clinically advanced cancer (stage cT3) undergo radical prostatectomy.
The study involved 5,652 men who had radical prostatectomy at the Mayo Clinic in Rochester, Minn., between 1987 and 1997. The start date of the study was chosen to correspond to the start of screening for prostate-specific antigen (PSA). Of those men, 842 (15%) were judged to have cT3 disease on the basis of two digital rectal examinations (DREs). They were followed for an average of 10 years.
Surgery revealed that 27% of the men had been overstaged on the basis of DRE and actually had cT2 disease, where the tumor had not grown beyond the capsule or into a seminal vesicle. At this stage, radical prostatectomy as monotherapy is potentially curable.
Lymph-node dissection during surgery revealed that another 27% had nodal metastases. These patients do especially well with adjuvant hormonal therapy. Had these patients been referred to radiotherapy instead of surgery, the patients who had been overstaged and those who had nodal metastases likely would have been missed.
The cancer-specific survival rate at 5, 10, and 15 years after surgery for correctly staged cT3 disease was 95%, 90%, and 79%, respectively. This was only moderately lower than survival rates for those patients who actually had cT2 disease; their cancer-specific survival rates were 99%, 96%, and 92%.
Erectile dysfunction was the most common morbidity associated with radical prostatectomy, and was experienced by 75% of the men in the study. This rate of erectile dysfunction compares favorably with those after radiotherapy for cT3 disease, Dr. Ward wrote (BJU Int. 2005;95:751–6).
Dr. Ward listed a number of reasons why radical prostatectomy might be preferable to radiotherapy, noting radiotherapy carries a high local failure rate for high-grade, high-volume disease. Surgery also eliminates the source of a late wave of metastasis, possibly leading to better long-term survival.
Nevertheless, “This study doesn't tell me that [surgery] is better than radiation,” Dr. Ward said at the press briefing. “An important thing here is that multimodal therapy is necessary for advanced prostate cancer. Whether [the primary therapy] is radiation or surgery, multimodal therapy has come of age. … We don't need to be competing as much.”
Dr. Ward is currently at the Nevada Cancer Institute, Las Vegas.