Issue 8 / 10 March 2014

PATIENT selection is key to maximising the benefits of radical prostatectomy, say Australian experts responding to the latest research on prostate cancer from a long-running Swedish study.

Professor Damien Bolton, a urologist and clinical professor of surgery at Austin Hospital Melbourne, told MJA InSight the study published in the New England Journal of Medicine was a win for the “moderates”. (1)

“Clearly [this study showed] there was a subgroup of patients — men under 65 with an intermediate-risk level of prostate cancer — who saw benefit from having surgery”, he said.

“This debate is a hot topic: there are those who are aggressive in their treatment and there are major naysayers. This study supports the position of the moderates.”

The trial randomly assigned 695 men with early prostate cancer to either watchful waiting or radical prostatectomy and followed them for up to 23.2 years.

At the end of follow-up, 63 men in the surgery group (17.7%) and 99 in the watchful waiting group (28.7%) had died of prostate cancer: an absolute risk reduction of 11% for those undergoing surgery.

Radical prostatectomy was also associated with a 12.2% absolute risk reduction in distant metastases (26.1% v 38.3%) and a 25% absolute risk reduction in the use of androgen deprivation therapy (42.5% v 67.4%), as well as a reduced requirement for other palliative treatments.

The mortality benefit from surgery was the largest in men aged younger than 65 years and in those with prostate cancer classified as intermediate-risk.

Dr Bolton said the results were clear. “For patients with intermediate-risk prostate cancer, radical prostatectomy has proved its worth.”

Professor Ian Haines, a medical oncologist at the Cabrini Hospital in Melbourne, said far too many radical prostatectomies were performed in Australia, arguing the case for more discriminating patient selection when offering surgical treatment.

He advised men with an increased prostate-specific antigen (PSA) score to get a second opinion.

“It is distressing the number of men who come to me for a second opinion, because they feel they have to have the surgery”, Professor Haines told MJA InSight.

“There are significant morbidities with this procedure. You’re looking at an artificial sphincter, impotence, incontinence — major quality of life issues.

“Yes, this study shows benefits of surgery for a group of patients.” However, he said, selecting the right patients for surgery was crucial.

“There is a dire need for an audit of all radical prostatectomies here”, he said. “Men with a PSA score of less than 10 shouldn’t be having surgery. We’re doing them in patients with scores of 1 or 2.”

Professor Mark Frydenberg, chairman of the department of urology at Monash Medical Centre, said the study results were timely.

“This study confirms that with prolonged follow-up that about a third of men still die from prostate cancer and two-thirds from other causes, hence highlighting that death from and not with prostate cancer remains a major clinical problem”, he told MJA InSight.

“It once again demonstrates the value of surgery in localised prostate cancer, especially for younger men with intermediate risk disease that should be the target of early detection strategies.”

 

1. NEJM 2014; 370: 932-942

9 thoughts on “Selection key in prostate surgery

  1. taylorr@amamember says:

    Men over 65 may also benefit from Radical Prostatectomy if, like me, they are on family form otherwise likely to live well into their late 90s or beyond. I chose that option at 67 and have no trace of secondaries three years later. (Still checking.) Sure I may have done well without surgery but who wants to live with the uncertainty of knowing you have low grade CA that MAY disseminate at some time.

  2. Samuel Leung says:

    The debate should be ‘active intervention’ vs observation rather than ‘surgery’ vs observation. It should not be forgotten that radiation treatment compares very favorably with surgery although there has never been a randomised head to head randomized trial. There are virtually NO patients that can not be safely treated with radiation compared with high risk surgical patients at risk of significant acute, chronic complications & even mortality.

  3. Guy Buters says:

    My experience suggests that the radical prostatectomy is being “oversold” by our urology colleges. They appear to be understating the rate of impotence and incontinence to their patients. The unfortunate pt is left impotent and dribbling with the promise that it may extend their life. Personally I consider either complication unacceptable and therefor would not have my PSA tested (I’m 52). As a profession we need to consider quality of life rather than length of life.  

  4. Bruce Connor says:

    How really comparable  are the two groups ?

    Were prostate biopsies done on all patents? And  was the histologcal cancer grading overall comparable between the two groups? What % had extra capsular extenson?  What is mean by intermediate risk prostate cancer?

     

  5. Ehud Zamir says:

    To “Concerned Medico”: PSA screening in the absence of a palpable prostate mass has been, to my knowledge, shown to be mostly related to the total prostate mass and often simply due to BPH. It was shown by a large American study some ?5 years ago. Like you, I will not have PSA tested but perhaps a simple rectal exam will tell me whether or not I need to test further. Note the results show that even with radical prostatectomy almost 20% still died from it, so this is not guaranteed cure. The magnitude of the effect is moderate, not huge, given the morbidity.

     

  6. Sue Ieraci says:

    I haven’t heard this discussed, but I suspect PSA has become a substitute for digital rectal examination where patient and/or doctor are reluctant due to ”yuk factor”. What do others think?

  7. Dr Kevin B. ORR says:

    The problem with “quality of life is better than length of life” is that the smokers, heavy drinkers and others that seek pleasure over health, can say the same thing!.

    KBO

  8. George Hamor says:

    I tend to agree with  RadOnc.

    The study is unhepful because to my knowledge no-one advocates “watchful waiting” these days; it is all about Active Surveillance.

    The question also needs to be asked: Why is/was there ANY mortality in the RP group?

    The answer is, we don’t know. Many more studies need to be done on non-aggressive prostate cancer before we can predict with certainty how to advise patients.

    I have been diagnosed with such disease recently, I have sought out expert opinions and read as much as I can about the subject. I favour AS, mainly because I am reluctant to accept morbidity from surgery when the outcome is unpredicatble.

    Immune modulation is likely to be the treatment of choice in the future; surgery may well be a thing of the past.

  9. Dr Mark Faigen says:

     This article shows a distinct, but not a huge , benefit, in treating intermediate prostate cancer, with Radical Prostatectomy, as compared with , watchful waiting. ( 11% reduction in prostate cancer deaths ) The findings , provide important information, that can be used , in discussing the pros and cons of Surgery, with patients.

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