Immediate vs. deferred radical prostatectomy for localized prostate cancer

A retrospective analysis of data from the Swedish National Prostate Cancer Register suggests that deferring radical prostatectomy for a year or more has minimal impact on prostate cancer-specific survival for men with localized prostate cancer.

Holmström et al. used the Swedish National Prostate Cancer Register to identify men of ≤ 70 years of age diagnosed with low- or intermediate-risk, localized prostate cancer between 1997 and 2002 who subsequently received a radical prostatectomy. The database includes about 90 percent of all men who received a diagnosis of incident localized prostate cancer in Sweden in this time period.

They then divided the patients into two groups to analyze their outcomes:

  • Group A comprised  2,344 men who underwent “immediate” primary radical prostatectomy (at a median of 3.5 months after diagnosis).
  • Group B comprised 222 men who received a deferred radical prostatectomy (at a median of 19.2 months after diagnosis) after a period of surveillance.

The men who had deferred surgery normally did so because of a rise in their PSA level (112 men), some other indicator of prostate cancer progression (20 men), or other reasons (87 men).

The results of the analysis showed that:

  • Upgrading of Gleason score in surgical specimens as compared to core biopsies at diagnosis was less common among patients in Group A (25 percent) as compared to Group B (38 percent); this was a statistically significant difference.
  • Positive surgical margins were more common among the men in Group A (at 33 percent) than they were among men in Group B (24 percent), but this difference was not statistically significant.
  • Extraprostatic extension was more common among the men in Group A (at 27 percent) than they were among men in Group B (25 percent), but this difference was, again, not statistically significant.
  • At a median follow-up of 8.2 years from the date of diagnosis, 16/2,344 men in Group A (0.7 percent) and 2/222 men in Group B (0.9 percent) had died of prostate cancer.
  • At the same median follow-up, 145/2,344 men in Group A (6.2 percent) and 12/222 men in group B (5.4 percent) had died of other causes.

The authors conclude that there was no significant difference in the presence of adverse pathology features or in prostate cancer-specific mortality after primary as compared to deferred radical prostatectomy. However, the authors do acknowledge that longer follow-up is needed to conclusively evaluate whether deferred radical prostatectomy can be considered to have equivalent clinical impact to immediate radical prostatectomy in this set of patients.

A Reuters commentary on this article is misleadingly headed “No risk seen from delaying prostate cancer surgery.” While that heading is in fact true, it seriously discounts the fact that median follow-up for the men in  this study was only 8.2 years as compared to the 15+ years that might reasonably be required to draw the conclusion suggested in the heading.

It is also important to appreciate that the data reported by Holmström and her colleagues do not represent data from a prospective clinical trial (in which patients would have gone onto active surveillance only if they met specific study criteria). These patients were all being treated in the community setting based on simple discussion between the doctor and his or her patient and the decisions reached by each pair of individuals. At the time that these men were treated, Sweden had no national guideline on the appropriate use of active surveillance.

What this study does do, however, is help to further confirm the reported data suggesting that active surveillance with deferred treatment as needed for men with low- and intermediate-risk prostate cancer is a reasonable clinical strategy.

7 Responses

  1. I wonder what is the upside of choosing to defer the surgery if [the patient] chooses to do it in any case. The only advantage I can think of is the additional year of enjoying life with less potential side effects.

    Isn’t the biggest downside the potentially increased risk of extraprostatic extension? I am surprised there was no significant increase in that.

    Does the study looked also at seminal vesicle invasion?

  2. I would hardly use ‘only’ as a modifier of advantage, Reuven. It seems like ‘hugely significant’ would be a much better modifier. Heck, if the ‘side’ effects weren’t so devastating, it would make some sense to preventatively remove every man’s prostate once he was done having kids, right?

    It’s a false dichotomy to pit ‘quantity’ and ‘quality’ against each other. They both matter and men deserve treatment (including AS/WW) that gives them a shot at both.

  3. Dear Reuven:

    The whole point of the study is to show that the patients who subsequently decided that they did need surgery after an initial period of surveillance were able to have it with no significant impact on their outcomes. The entire patient cohort included > 8,000 patients, of whom 2,021 started on surveillence. Of these 2,021 patients, 1,328 remained on surveillance, 277 had deferred surgery (of whom only 222 had sufficient data for analysis in this study), 207 had deferred radiation therapy, and 209 had deferred hormone therapy. It is possible that the outcomes of the radiation patients and the hormone therapy patients will be discussed in detail in a future publication. The study makes no mention of the pathology of the seminal vesicles.

    These patients did not set out to defer surgery. They set out to see if they could avoid treatment entirely. About 66% (1,328/2,021) of all the patients who initially chose this pathway were able to continue down it, with great success. Only 14% (277/2,021) subsequently received surgery.

  4. What happened to the roughly 600 in the surveillance cohort that didn’t have deferred therapies? That’s what I want to know.

  5. See my answer to Reuven’s question above. I’m not sure where you got 600 from.

  6. Oops, I’m sorry. I read the commas incorrectly — 1,328 + the deferred therapies = 2,021. Got it.

    Wonder if they’re still following 1,328.

  7. I believe we will see further data on these patients. This is one of the advantages of having a sophisticated national prostate cancer registry into which the vast majority of the data for all patients is entered over time.

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