The role of radical prostatectomy in older males with high-risk prostate cancer

Data reported earlier this year from the PIVOT study and separately from the long-term Scandinavian study have shown that the surgical treatment of prostate cancer in the patients enrolled in these trials showed no median prostate-cancer specific or overall survival benefit compared to watchful waiting in patients of > 65 years of age. However, what this does not mean is that advanced chronological age should be some form of absolute contraindication for radical prostatectomy. Individual patients need to be carefully considered on their merits. Indeed data from the PIVOT trial did indeed suggest that — in that trial — there might well have been a benefit from surgery in men with localized but high-risk disease.

Rogers et al. have carried out a recent, retrospective analysis of data from a series of 69 men, all greater than 70 years of age and all treated with robot-assisted laparoscopic prostatectomy (RALP) between April 2001 and November 2009. In addition, all 69 patients met at least one of the three D’Amico criteria for high-risk prostate cancer.

The key results of this retrospective analysis are as follows:

  • Pre-surgical risk data showed that
    • 11/69 patients (16 percent) had a PSA > 20 ng/ml.
    • 43/69 patients (62 percent) had a Gleason score of 8.
    • 25/69 patients (36 percent) had a clinical stage of T2c.
  • Significant perioperative issues included
    • Two cases of urine leakage
    • Two cases of ileus (blockage of the bowel)
    • An average (median) blood loss of 150 cm3
  • The average (median) hospital stay was 1 day
  • No patient had a hospital stay of > 3 days
  • Post-surgical pathology data showed that
    • 26/69 patients (38 percent) had organ-confined disease with negative surgical margins.
    • 27/69 patients (39 percent) had extracapsular disease with negative surgical margins.
    • 1/69 patients (1 percent) had positive lymph nodes.
    • Data are not immediately available on the remaining 15 patients.
  • Biochemical recurrence was evident in 12/69 men (17 percent) at a median follow-up of 37.7 months.
  • The actuarial rates of biochemical recurrence-free survival were estimated to be
    • 91 percent at 12 months post-surgery
    • 86 percent at 36 months post-surgery

In addition, the authors report quality of life data based on functional outcomes assessed through the use of patient-administered questionnaires:

  • Questionnaires were completed at a median follow-up of 26.2 months.
  • Patients demonstrated a significant improvement in median International Prostate Symptom Score (IPSS)  — from 8.0 before surgery to 5.0 at time of assessment.
  • 53/65 men reported using one pad per day (or less) for urine control.
  • 7/21 men (33 percent) with a pre-surgical Sexual Health Inventory for Men (SHIM) score of > 21 reported “erections sufficient for intercourse.”

It is important to emphasize that we have not reviewed the full text of this paper. Additional data on this series of patients is undoubtedly available in the full text.

The clear take-away from this paper (and from others that have also addressed the treatment of pre-surgically defined localized prostate cancer in older males) is that radical prostatectomy — robot-assisted and otherwise — remains an appropriate option for carefully selected men of 70 years and older, and particularly for those older men with high-risk disease who are otherwise in good health and have a life expectancy of at least 10 or 15 years. The idea that chronological age alone should somehow be an absolute contraindication to surgery is not justified by available data. Equally, however, surgery is probably not a good option for the majority of men with localized prostate cancer who are > 65 years of age. In many such men, the potential risks associated with surgery do not appear to be counterbalanced by a greater degree of benefit.

2 Responses

  1. As time passes the actuarial rate of recurrence goes down? There is something in that sentence that I do not understand.

  2. John:

    You are correct. It sound have said “biochemical recurrence-free survival” (and has now been corrected).

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