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More on the role of first-line surgery in high-risk patients

Posted Dec 17 2009 12:00am

As a follow-up to yesterday’s report on Scardino’s presentation to the New York section of the AUA, it is worth noting a publication last November from Johns Hopkins. The research group’s goal was to investigate long-term survival following radical prostatectomy as first-line treatment in their patients with high-risk prostate cancer.

According to Loeb et al., between 1992 and 2008, a single surgeon (presumably Patrick Walsh) treated 175 men with D’Amico high-risk prostate cancer (clinical stage ≥ T2c, biopsy Gleason score 8-10, or PSA > 20 ng/ml) with radical prostatectomy at Johns Hopkins. A careful analysis of data from these patients showed the following:

  • 63/175 patients (36 percent) had organ-confined disease.
  • At 10 years, for this subset of 63 patients only,
    • Biochemical recurrence-free survival  was 68 percent.
    • Metastasis-free survival was 84 percent.
    • Prostate cancer-specific survival was 92 percent.
    • The rate of freedom from any hormonal therapy was 71 percent.
  • Of the high-risk criteria, a biopsy Gleason score of 8-10 (as compared to a Gleason score of ≤ 7) was the strongest independent predictor of biochemical recurrence, metastases, and prostate cancer death.

The authors also note that, despite considerable stage migration associated with widespread PSA screening, during the time frame covered by this study, up to a third of incident prostate cancers have had high-risk features. It has been customary to treat many of these patients with combined radiation and androgen deprivation therapy. They state that it is possible that RP is underutilized for the management of high-risk, clinically localized prostate cancer.

Loeb et al. conclude that the Hopkins data “suggest that surgical treatment can result in long-term progression-free survival in a subset of carefully selected high-risk men.”

It would have been helpful if the Hopkins group had provided 10-year follow-up data for all 175 of these patients, and not just the ones with apparently organ-confined disease at the time of surgery. This would have allowed a more direct comparison of the Hopkins data to the Memorial Sloan-Kettering data presented by Scardino. However, we will have to do the best we can with what is available! In a previous paper based on the Johns Hopkins series of patients, Trock et al. had already shown that, “Salvage radiotherapy administered within 2 years of biochemical recurrence was associated with a significant increase in prostate cancer-specific survival among men with a prostate-specific antigen doubling time of less than 6 months.” This paper was cited by Scardino in his presentation as confirming his opinion that second-line radiotherapy was an important option for treatment of men with high-risk prostate cancer after initial treatment with surgery.

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