Is salvage radical prostatectomy really being under-used?

A new paper in the journal Clinical Genitourinary Cancer states that, “Salvage radical prostatectomy (SRP) is a treatment modality for patients with radio-recurrent prostate cancer but is currently underutilized.” The “New” Prostate Cancer InfoLink is significantly less than convinced of that premise.

Pokala et al. do not provide actual clinical data of any type to support the above assertion. What they did was use data from the Surveillance, Epidemiology, and End Results (SEER) registry to identify patients who underwent radical prostatectomy after prior radiation therapy between 1988 and 2010 and then to look at the long-term survival of those patients.

Here is what they report:

  • The SEER database included 2,628 patients with prostate cancer who had SRP after primary radiation therapy.
  • Only 364/2,628 of these patients (13.8 percent) were deemed “eligible” for inclusion in the study — but the abstract doesn’t tell us why.
  • No data were available on
    • The PSA status of the patients at any point in time
    • Whether or not the patients received or required any form of androgen deprivation therapy either before or immediately following their surgery
  • For those 364 patients
    • The overall survival rate was
      • 77.5 percent at 10 years
      • 37.3 percent at 20 years
    • The prostate cancer-specific survival rate was
      • 88.6 percent at 10 years
      • 72.7 percent at 20 years
  • The risk for death was higher among men who did not have a pelvic lymph node dissection compared to those who did
    • Hazard ratio [HR] = 1.4 for overall survival.
    • HR = 2.7 for prostate cancer-specific survival.

The authors then conclude (among other things) that

Excellent long-term survival can be achieved with SRP.

Now that conclusion, i.e., the “can be” statement, is actually true … even though it is not justified by this particular paper.

SRP — in the hands of a small number of very highly skilled and experienced surgeons, who have the ability and experience to select highly appropriate patients — is an operation that can actually be used to cure radio-recurrent prostate cancer, or at least to place patients back into long-term remission. No one has questioned this for years. The critical issues, however, are twofold:

  • Who is an appropriate candidate for such a procedure?
  • Who has the ability to carry out such a procedure successfully while limiting the risk for the well-appreciated side effects that are associated with SRP, specifically including complete loss of erectile/sexual function (which is commonplace) and a very high risk for long-term incontinence.

Since we have no idea why the authors determined that 76.2 percent of the patients they identified in the SEER database were not eligible for inclusion in their study, we cannot question the outcomes they report. For example, it may well be that they were only able to find long-term outcomes data for 364/2,628 patients. But if that is true, then the conclusion is open to question anyway. In their defense, the authors do state that, “Small sample sizes limit the overall power of this study.”

The “New” Prostate Cancer InfoLink wishes to be clear that SRP is quite certainly an appropriate treatment option for carefully selected patients who have a biochemical recurrence after first-line treatment with any form of radiation therapy (or indeed after other treatments such as high-intensity focused ultrasound [HIFU] or focal laser ablation [FLA]). We believe that the majority of patients having an SRP should also have a pelvic lymph node dissection at the time of that SRP.

We also wish to be clear that SRP is often a very difficult operation to perform well, for a whole host of reasons. We don’t even have particularly helpful data on just how many surgeons in the USA (or other countries) could or would actually claim to have carried out enough such surgeries to have high confidence in their ability to obtain reasonable long-term outcomes in most of the patients they would be willing to operate on. However, …

What is a very great deal less clear is just what percentage of men with radio-recurrent (or HIFU-recurrent or FLA recurrent) prostate cancer are really good candidates for SRP and how to distinguish the really good candidates from the less good. A recent paper by Bates et al. reports data on the actual, short-term outcomes of a small series of patients who received a robot-assisted SRP at one high-volume US-based institution. A recent review by Matei et al. provides us with what appears to be the best, recent assessment of the role of SRP in the management of radio-recurrent prostate cancer. Table 1 and Figures 1 and 2 in that paper give some further perspective on patient outcomes. Matei et al. also emphasize the following point made above:

The careful evaluation of SRP prognostic factors is of paramount importance for the appropriate selection of patients.

It is worth noting that, in the data reviewed by Matei et al., they report only six published studies that included 100 or more patients who had undergone SRP. That in itself is an indication that the majority of academic surgeons are not enthusiastic about performing this operation.

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