We have no data from randomized trials on the relative effectiveness of surgery compared to radiation therapy in the treatment of men initially diagnosed with clinical stage T3NxM0 prostate cancer. However, we do now have data from > 800 men treated with radical prostatectomy (RP) and followed for up to 23 years at the Mayo Clinic.
Mitchell et al. conducted a retrospective analysis of data on the thousands of men treated by radical prostatectomy at the Mayo Clinic between 1987 and 1997. Based on that analysis, they offer the following information:
- 843 men were treated by first-line radical prostatectomy alone after a diagnosis of clinical stage T3NxM0 disease.
- Average (median) post-surgical follow-up was 14.3 years (range 0.1 to 23.5 years).
- 223/843 patients (26.5 percent) were found to have pathological T2N0M0 disease post-surgery.
- At an estimated follow-up of 20 years (based on Kaplan-Meier methodology)
- Local recurrence-free survival for all patients was 76 percent.
- Systemic progression-free survival for all patients was 72 percent.
- Prostate cancer-specific survival for all men 81 percent.
- On multivariate analysis, an increased risk for prostate cancer-specific mortality was evident in men with
- Higher pathological Gleason scores (hazard ratio [HR] = 1.8)
- Non-diploid chromatin content (HR = 1.8)
- Positive surgical margins (HR = 2.1)
- Seminal vesicle invasion (HR = 2.1)
- A more recent year of surgery was associated with a decreased risk of cancer-specific mortality (HR = 0.88).
Mitchell et al. conclude that:
- “RP affords accurate pathological staging and may be associated with durable cancer control for cT3 prostate cancer, with 20 years of follow-up.”
- “RP as part of a multimodal treatment strategy therefore remains a viable treatment option for patients with cT3 tumors.”
However, they are also careful to note that external beam radiation therapy in combination with androgen deprivation therapy offers 10-year progression-free survival among about 88 percent of men when given as first-line therapy for men initially diagnosed with cT3 disease. The combination of radiation therapy and ADT may well (therefore) be the most appropriate form of treatment for older men initially diagnosed with cT3 disease.
The bottom line is that for those men with what may be the earliest stages of cT3 disease on diagnosis (and who may therefore turn out to have pT2 disease post-surgery) — and particularly for younger men who may be able to recover well after radical prostatectomy — surgery is still a very appropriate form of first-line treatment that can always be followed later with adjuvant or salvage radiation therapy (with or without ADT, as necessary). Careful patient selection and a thorough discussion of the risks and benefits of such an approach are clearly key factors in the application of such a clinical strategy.