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The role of surgery as first-line treatment for high-risk prostate cancer: Part III

Posted Dec 19 2009 12:00am

Earlier this week we published reports on work from Memorial Sloan-Kettering Cancer Center and Johns Hopkins regarding the role of surgery as first-line treatment for men with high-risk prostate cancer. The topic appears to be coming into fashion.

A French research team has now reported on rates of biochemical progression-free survival (bPFS)  in patients at high risk of disease progression who received laparoscopic radical prostatectomy (LRP) as their first-line treatment. (The MSKCC and Hopkins data were predominantly and exclusively based on patients treated by open surgery.)

All patients were treated between October 2000 and May 2008 and met the preoperative criteria of D’Amico et al. for high risk (a PSA level of >20 ng/ml and/or a biopsy Gleason score ≥ 8 and/or a clinical stage of T2c-T4). A total of 110 patients were treated, and all patients had extraperitoneal LRP and bilateral pelvic lymph node dissection.

The results were as follows:

  • Prostate cancer was organ-confined in 40/110 patients (36 percent).
  • The overall rates of bPFS were 79.4 percent at 1 year and 69.8 percent at 3 years.
  • The 3-year rates for bPFS for patients with organ-confined cancer vs those with extracapsular extension were 100 percent and 54.3 percent, respectively.
  • The 3-year rates for bPFS for patients who showed no sign of cancer in their seminal vesicles vs those with seminal vesicle invasion were 81.8 percent and 33.6 percent, respectively.
  • The 3-year rates of bPFS for patients with negative as opposed to positive surgical margins were 85.2 percent and 47.3 percent, respectively.
  • Compared with men with just one or any two pathological risk factors, men with all three risk factors had a significantly shorter time to PSA failure after LRP.

Ploussard et al. conclude that in this group of patients, all at increased risk of disease progression as defined by the D’Amico pre-treatment criteria, the men with truly organ-confined disease have a particularly favorable prognosis. The authors also state that the patients at high risk for early PSA failure could be better identified by pathological assessment of the radical prostatectomy specimens, and should then be encouraged to enroll in randomized clinical trials investigating adjuvant systemic forms of treatment.

This study does not help us to confirm or deny Scardino’s suggestion that radical surgery may be better reserved for men with higher-risk prostate cancer. However, it does further confirm that some 30-40 percent of these patients have organ-confined disease, and it does confirm the extended period of bPFS in the patients who do have organ-confined disease.

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