THE “NEW” PROSTATE CANCER INFOLINK

Two publications in a recent issue of Urology add to the available information about surgical management of low-risk prostate cancer, but offer little further guidance as to the decision-making process for newly diagnosed patients.

Hernandez et al., from Johns Hopkins, have demonstrated in a retrospective analysis of their series of 2,526 patients that men with prostate cancer who undergo radical prostatectomy and have pathologically organ-confined disease with a Gleason score 6 or less are very unlikely to experience disease recurrence. In addition, Loeb et al. have evaluated the outcomes and surgical complications of low-risk patients who underwent radical prostatectomy.

Hernandez et al. identified 2,526 men who received a radical prostatectomy between 1983 and 2005 (2,422 open procedures and 104 laparoscopic). All had pathologic organ-confined disease and a Gleason score of 6 or less. Their median age was 58 years, and their median preoperative PSA was 5.2 ng/mL. Almost 72 percent had cclinical stage T1c disease. A total of 52 percent had 5 years or more of follow-up and 18 percent had more than 10 years follow-up. A local recurrence was identified in just five men, and four of these had salvage radiotherapy. No patient developed distant metastasis. Death from other causes occurred in 77 patients (3 percent) and no prostate cancer-specific mortality occurred. The probability of biochemical recurrence at 5, 10, and 15 years was calculated as 0.3, 0.9, and 1.3 percent, respectively.

The authors were not able to determine which men had “insignificant cancer” based upon tumor volume at the time of radical prostatectomy. However, by applying pre-surgical PSA and needle biopsy data, they were able  to identify 268 men (10.6 percent) who had insignificant tumors at the time of radical prostatectomy.

A retrospective review identified 2,526 men between 1983 and 2005 who underwent RP, either open (2,422) or laparoscopic (104). All had pathologic organ confined disease and Gleason score 6 or less cancer. Median age was 58 years, and median preoperative PSA was 5.2ng/ml. Almost 72% had cT1c disease. A total of 52% had 5 years or more of follow-up and 18% had more than 10 years follow-up. A local recurrence was identified in 5 men and 4 of these had salvage radiotherapy. No patient developed distant metastasis. Death from other caused occurred in 77 patients (3%) and no prostate cancer specific mortality occurred. The Kaplan-Meier survival analysis for actuarial probability of biochemical recurrence at 5, 10, and 15 years was 0.3%, 0.9%, and 1.3%, respectively. The 5, 10, and 15 year actuarial probability of local recurrence was 0.1%, 0.5%, and 0.5%, respectively.

The authors were not able to determine which men had “insignificant cancer” based upon RP tumor volume, but by applying PSA and needle biopsy data they identified 268 men (10.6%) who had insignificant tumors at RP.

Between 1983 and 2006, 4,265 men underwent RP by Dr. William Catalona. Loeb et al. have identified men from Catalona’s surgical series that met at least one of three published sets of criteria for eligibility for active surveillance:

• the Patel definition (Gleason score 7 or less and no significant comorbidities)
• the Choo definition (clinical stage T1b-T2bN0M0, Gleason 7 or less, and a PSA of 15ng/ml or less)
• the Mohler definition (clinical stage T1c)

They found 3,458, 3,533, and 2,338 men, respectively, who met these criteria. Oncologic outcome, potency and continence were evaluated for each group of these patients. Stratified by age, there were 298 men (7 percent) in their 30s and 40s, 1,496 men (35 percent) in their 50s, 1,934 men (45 percent) in their 60s, and 536 men (13 percent) in their 70s or older.

• Based on the Patel criteria, mean preoperative PSA was 7.1 ng/mL. The database identified most of the patients as Caucasian with a pre-surgical Gleason score of 6 or less and a clinical stage T1c or T2, treated with bilateral nerve sparing surgery. At a mean follow-up of 5 years, 90 percent were continent, 62 percent were potent, and 7 percent had surgical complications.
• Based on the Choo criteria, mean PSA was 5.9 ng/mL and, at a mean follow-up of 54 months, 90 percent were potent, 63 percent were continent, and 7 percent had complications.
• Based on the the Mohler criteria, mean PSA was 6.7 ng/mL and, at a mean follow-up of 42 months, 90 percent were continent, 63 percent were potent, and 5 percent had surgical complications.

The risk of erectile dysfunction increased with increasing age, preoperative PSA, biopsy Gleason score, and clinical stage. Medical comorbidities and non-nerve-sparing surgery were significantly associated with potency. The risk of surgical complications was directly related to increasing age, PSA and clinical stage, with age the strongest predictor of continence:

• Men in their 40s had continence rates of about 96 percent, potency rates of 93 percent, and complication rates of about 4 percent.
• Men in their 50s had similar outcomes, but the potency rates were less at 80 percent.
• Men in their 60s had continence rates of 94 percent and potency of up to 69 percent.
• Men aged 70 and over had continence rates of 70 percent and potency of 46-59 percent with a surgical complication rate of up to 13 percent.

These two studies clearly show that top-notch surgeons such as Walsh and Catalona can achieve high quality outcomes in men with low-risk prostatate cancer. What they do not help us to understand is how many of these men might have fared just as well (or perhaps better from a quality of life point of view) if they had not undergone surgery at all — particularly in the case of those men in the 70 and older age group who were at highest risk for complications and also (presumably) at lowest risk for death from prostate cancer.