Whole-gland cryotherapy vs. radical prostatectomy as first-line treatment for localized disease


Over the years there have been very few studies that have attempted to make any type of direct comparison between outcomes of patients treated with whole-gland cryotherapy and outcomes of patients treated with other standard forms of whole gland therapy for localized prostate cancer.

A new paper by Elkjær and Borre now offers data for such a direct comparison from patients treated at a major Danish hospital (Aarhus University Hospital) between 2006 and 2012.

The goal of this study was to compare the oncological outcomes of patients receiving cryoablation of the prostate as first-line treatment for localized prostate cancer to the oncological outcomes of patients treated by radical prostatectomy over 7 years of parallel use.

The authors enrolled all patients undergoing whole-gland cryotherapy and all patients undergoing radical prostatectomy for localized prostate cancer into a prospective, institutional data registry. Patients were followed for a minimum of 12 months (if there was no sign of recurrent disease), and recurrence among the cryotherapy patients was defined according to the Phoenix criteria (nadir PSA + 2 ng/ml).

Here are the study findings:

  • 40 whole-gland cryotherapy procedures were carried out in 39 different patients (i.e., one patient was treated twice).
  • Average (median) patient age at time of cryotherapy was 65 years (range, 47 to 78 years).
  • Median follow-up was 27.9 months (range, 4 to 75 months).
  • No cryotherapy patients were excluded from the analysis.
  • 13/39 patients (33 percent) had recurrent disease after whole-gland cryotherapy.
  • When these patients were categorized by D’Amico risk level
    • 2 recurrences were observed in 6 cases of low-risk disease (33 percent).
    • 5 recurrences were observed in 21 cases of intermediate-risk disease (24 percent).
    • 6 recurrences were observed in 13 cases of high-risk disease (46 percent).
  • 350 radical prostatectomies were carried out during the same time period.
  • Median follow-up after radical prostatectomy was 37 months (range, 16 to 54 months).
  • Average (median) patient age at time of radical prostatectomy was 64 years (range, 34 to 76 years).
  • No radical prostatectomy patients were excluded from the analysis.
  • 62/250 patients (18 percent) had recurrent disease after radical prostatectomy.
  • When these patients were categorized by D’Amico risk level
    • 3 recurrences were observed in 102 cases of low-risk disease (3 percent).
    • 30 recurrences were observed in 144 cases of intermediate-risk disease (21 percent).
    • 29 recurrences were observed in 104 cases of high-risk disease (28 percent).
  • The risk of prostate cancer recurrence was significantly higher after whole-gland cryotherapy than after radical prostatectomy (p < 0.001).

The authors conclude that, at their institution, oncological outcomes after whole-gland cryotherapy have been inferior to oncological outcomes after radical prostatectomy and that recurrence after whole-gland cryotherapy “was high regardless of risk group, indicating a risk of treating and leaving the tumor in situ. Even small low-risk tumors have the potential for recurrence.”

Now it can certainly be argued that the skill level of the cryotherapist at this institution may have been low (after all, 40 cryotherapies over 7 years is not exactly a high throughput). It is also possible that highly skilled cryotherapists are able to obtain significantly better outcomes. However, these data do not give one confidence that whole-gland cryotherapy is really a high-quality option for the first-line treatment of localized prostate cancer.

We do wish to point out, however, that these data do not preclude the possibility that focal cryotherapy may be a very valid therapeutic option for men with small, well-defined foci of low- and intermediate-risk prostate cancer.

One Response

  1. The experience factor of the physicians certainly is a major factor. Surprised that you didn’t make a comment that the low volume of both groups will question the statistical value of this study. Certainly, with the data on hand, your conclusions are right on.

    Too bad that centers like the USMD Prostate Cancer Center in Texas (which has performed thousands of cryotherapies and robot-assisted prostatectomies) doesn’t offer similar data.

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