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Is surgery best reserved for first-line treatment of higher-risk prostate cancers?

Posted Dec 16 2009 12:00am

One of the characteristics of a great clinician is the ability to continue to learn, to revise one’s opinions, and even radically change one’s mind based on experience. And in a recent presentation to the New York Section of the American Urological Association, Scardino has again demonstrated these very specific capabilities.

Scardino’s presentation addresses the general issue of the appropriateness of surgery as a first-line treatment for prostate cancer. But a core focus of the presentation includes a comparative analysis of the use of surgery as opposed to external beam radiation therapy as first-line therapy in patients believed to have locally advanced forms of prostate cancer. And it should be stated up front that this analysis was carried out with the full cooperation and participation of the radiation oncology group at Memorial Sloan-Kettering Cancer Center (MSKCC). The entire presentation is available on the UroToday web site for registered users (at no cost), and the critical information is provided in slides 4 through 11. The data presented in these specific slides are yet to be formally published.

Here is what Scardino told his audience in this portion of his presentation:

  • We know that surgery works as a treatment for early stage prostate cancer.
  • What is surprising is how well it seems to work for men with locally advanced disease, where patients with pathological stages T3bN0 and T1-3N+ have cancer-specific survival rates of > 70 percent.
  • What is even more surprising is that in patients with locally advanced disease, first-line surgery is associated with a much lower risk for subsequent metastasis and prostate cancer-specific mortality than first-line radiation therapy.
    • The risk for metastases after first-line surgery in these patients was 0.32 compared to patients receiving first-line radiation.
    • The risk for prostate cancer-specific death after first-line surgery in these patients was 0.35 compared to patients receiving first-line radiation.
  • The reason for this seems to be related to the fact that when these patients get first-line surgery, they can get second-line radiation quickly when needed (within  an average of 13 months after first-line surgery), whereas when the patients get first-line radiation, they don’t get appropriate second-line (salvage) surgery until an average of 69 months has passed.

Scardino went on to talk about the fact that urologists need to become more acceptant of the reality that radical prostatectomy (by any technique) is a very difficult operation to learn to do well and may not be appropriate for all patients. He points out carefully that:

  • For patients with truly low-risk cancer, with pathologically proven Gleason grade 6 disease (or lower based on older pathological staging), the risk of prostate cancer-specific mortality is now minimal, at around 2 percent of all such patients.
  • Even highly experienced surgeons exhibit considerable variation in their outcomes over time.
  • It takes about 250 operations to learn to do a radical prostatectomy well.
  • Even then, good surgeons are improving their skill and technique until they have done at least 1,000 procedures.
  • Within the MSKCC database, there is clear evidence that laparoscopic surgery has been associated with lower levels of continence and a greater risk for readmissions for additional surgery than open surgery.

Scardino concludes by presenting the following personal viewpoint:

  • When well performed, surgery provides excellent control of localized prostate cancer (cT1-cT3a disease).
  • Surgery is an appropriate first-line treatment for men with selected, high-risk cancers (cT3, Gleason 8-10, PSA > 20).
  • Surgery should be reserved for men with forms of prostate cancer that present a “meaningful threat” for long-term metastasis and prostate cancer-specific death
  • Surgery should not be used as a first-line treatment for men with low-risk cancers or elderly men.
  • Radical prostatectomy is a “technically challenging” procedure that is commonly associated with “troublesome” complications and side effects.
  • Achieving cancer control and achieving full recovery of continence and erectile function (the “trifecta”) is difficult (even for experienced surgeons).
  • Surgical outcomes are extremely sensitive to individual surgical technique.

Also during the course of this presentation, Scardino more than once makes the point that surgery is so successful at preventing prostate cancer-specific deaths for patients with low-risk disease that “one has to ask oneself” whether many of those patients couldn’t just be monitored and treated later if necessary.

There would be little argument in  the urologic oncology community that Dr. Scardino is one of the very best prostate cancer surgeons of his generation — if not the best. For him to be making a presentation of this type with this degree of clarity would again suggest to The “New” Prostate Cancer InfoLink that there is a major mindset shift taking place in the urology community about who really should get immediate surgical treatment for very early stage prostate cancer. It is clear that Dr. Scardino and his colleagues at MSKCC have already come to some specific conclusions — although they may still find themselves under pressure from newly diagnosed, low-risk patients to “just get it outta there.”

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