SAN ANTONIO - In patients with clinically advanced (cT3)
prostate cancer, radical prostatectomy supplemented with other treatment
modalities provides outcomes approaching those typically seen in patients
with cT2 prostate cancere.
John F. Ward, MD, chief of urologic surgery, Nevada Cancer
Institute, Las Vegas, presented the findings at the 100th Annual Meeting of
the American Urological Association (abstract 826).
Best Management Controversial
The best management of cT3 patients remains controversial.
"There has been a perception that performing surgery in patients with locally
advanced prostate cancer is associated with increased incontinence, bleeding,
and perioperative morbidities for little improvement in cancer control," Dr.
Ward told ONI.
To objectively evaluate the long-term safety and efficacy of
radical prostatectomy in patients presenting with cT3 disease, Dr. Ward and his
colleagues carried out a retrospective analysis of 5,652 patients from the Mayo
Clinic Prostate Cancer Registry (median age, 66 years) who underwent
prostatectomy during the PSA era (1987-1997). Patients were followed for a
median of 10.3 years (range, 1 month to 16.7 years). Clinical outcomes,
including survival, disease-free survival, and complication rates, were
compared based on disease stage.
Nearly 15% of the cohort (n = 841) underwent radical
prostatectomy despite having cT3 disease; 23% of these patients received
In the cT3 patients, cancer-specific survival rates over 5,
10, and 15 years were 95%, 90%, and 79%, respectively-only moderately lower
than the rates for the patients with cT2 disease (n = 4,810): 99%, 96%, and
Overstaging was prevalent among the 661 hormone-nave cT3
patients: Pathological examination of the prostate showed that 27% of these
patients had organ-confined disease (pT2). "For these men," Dr. Ward said,
"radical prostatectomy alone was potentially curative."
Multivariate analysis revealed several factors significantly
associated with increased risk of recurrence, including pathologic grade of at
least 7, positive surgical margins, and nondiploid chromatin. Baseline PSA,
however, had little impact on clinical outcome.
The incidence of perioperative complications was equivalent
between patients with cT3 and those with cT2 disease, as were continence rates.
Additionally, the median time to secondary therapy (4 years) was identical for
the two groups, although a greater proportion of cT3 patient required secondary
therapy (78% vs 41% of cT2 patients).
Dr. Ward concluded that in this study, "there appears to be
a significant cancer-specific survival advantage to removing the locally
advanced prostate cancer. Multimodal therapy is still necessary in the majority
of patients, but when compared to patients with similar clinically staged
disease who undergo radiation therapy and receive hormonal therapy, cancer
control and survival appear to be superior following surgery."
He noted that clinical trials are needed in these patients
to compare prostatectomy or radiation therapy as part of a multimodal treatment
regimen that includes hormonal therapy and/or chemotherapy. The full results of
the study were recently published (BJU International 95:751-756, 2005).