Long-term outcomes of radical prostatectomy for clinically advanced (cT3) prostate cancer

2011 AUA:  Surgery Works in Locally Advanced Prostate Cancer. 

MedPageToday interview with Dr. Jeffrey Karnes, Mayo Clinic. (Scroll down for the newspaper article plus 3 minute video.)

Dr. Barken’s Comments: 

This important abstract was presented to physicians at the 2011 American Urological Association Annual Meeting.

The crux of the article:  Many younger men with high risk prostate cancer are persuaded to stay away from surgery in favor of radiation treatments.   However, according to the Mayo Clinic,  younger patients should not automatically discard surgery as a viable option to consider.  Data is presented to show that radical prostatectomy works in locally advanced prostate cancer.   Accurate risk assessment is key to effective long term control.

 

By Charles Bankhead, Staff Writer, MedPage Today
Published: May 23, 2011
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

WASHINGTON — Men with locally advanced prostate cancer had a 20-year disease-specific survival of 81% following radical prostatectomy, data from a large clinical series showed.

The cohort had a progression-free survival (PFS) of 72% at 10 years and 61% at 20 years.

Though inferior to outcomes in patients with localized (cT2) cancer, the findings suggest that radical prostatectomy offers a reasonable therapeutic option associated with favorable long-term results for a group of patients with no clear standard of care, according to a presentation here at the American Urological Association meeting.

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Action Points


  • Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
  • Note that in this study of patients treated with radical prostatectomy, patients with locally advanced (cT3) prostate cancer, despite many high-risk features, had an overall survival rate at 20 years of 80%.

“Oncologic outcomes for men with clinical T3 disease remain favorable with long-term follow-up,” said Christopher Mitchell, MD, of the Mayo Clinic in Rochester, Minn.

“Radical prostatectomy, as part of a multimodality treatment strategy for patients with clinical T3 disease, offers durable cancer control and survival rates at 20 years. The results compare favorably with current strategies combining external beam radiation therapy and hormones.”

Locally advanced disease (cT3) accounts for a small percentage of all prostate cancer. Nonetheless, optimal treatment for this subset of patients remains unclear, said Mitchell. Despite a lack of evidence from randomized, controlled trials, however, a bias exists toward nonsurgical management of patients with unfavorable clinical features.

To determine the long-term success of radical prostatectomy in locally advanced disease, investigators retrospectively reviewed records of prostate cancer patients treated with radical prostatectomy from 1987 to 1997. Of 7,883 patients identified, 4,812 (61%) had cT2 (localized) disease and 843 (11%) had cT3 cancer.

Median follow-up was 14.3 years. The primary endpoints were PFS, cancer-specific survival, and overall survival among patients with cT2 and cT3 prostate cancer.

Consistent with previously reported data, pathology results showed that clinical overstaging occurred in 223 of 843 (26%) patients with cT3 disease (BJU Int 2005; 95: 751-756). As an aside, Mitchell said a more contemporary patient population (1997 to 2007) was analyzed, and the rate of overstaging was similar, despite presumptive use of MRI in more patients.

Investigators found no differences in the rate of postoperative complications between patients with cT2 and cT3 disease.

Patients with cT3 disease had significantly (P<0.0001) more high-risk features compared with the cT2 patients:

  • Preoperative PSA level, 10.2 versus 7.2 ng/mL
  • Pathologic grade ≥7, 59% versus 39%
  • Positive surgical margins, 56% versus 38%
  • Seminal vesicle invasion, 43% versus 17%
  • Nodal metastases, 27% versus 7%
  • Tumor volume, 4.2 versus 2.6 mL3
  • Aneuploidy, 14% versus 6%
  • Secondary therapy, 76% versus 42%

Patients with cT2 prostate cancer had significantly better 20-year results for all three endpoints: PFS, 84% versus 61%, P<0.001; prostate cancer-specific survival, 94% versus 81%, P<0.001; and overall survival, 90% versus 80%, P<0.001.

Multivariate analysis revealed five factors that predicted an increased risk of systemic progression or local recurrence: pathologic grade ≥7, higher preoperative PSA level, ploidy, seminal vesicle invasion, and positive surgical margins (P=0.033 to P=0.004).

During the discussion that followed his presentation, Mitchell acknowledged that a limitation of the study was the inability to examine the impact of adjuvant therapies on outcomes and possibly identify patients who could avoid secondary treatment and associated adverse effects.

“Obviously the goal would be to save some of these patients exposure to radiation or hormonal treatment,” said Mitchell. “There was nonstandardized application of these secondary therapies. The 76% rate in our clinical T3 population was higher than has been reported in other studies.”

Primary source: American Urological Association
Source reference:
Mitchell C, et al “Long-term outcomes of radical prostatectomy for clinically advanced (cT3) prostate cancer” AUA 2011; Abstract 339.
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