Surgery Offers Long-Term Benefit in Clinical T3 Prostate Ca

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).

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 neoadjuvant therapy.

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 92%, respectively.

Overstaging was prevalent among the 661 hormone-naïve 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).