Does radical prostatectomy provide a survival benefit as primary treatment for high-grade prostate cancer?

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Abstract

BACKGROUND

Primary treatment for advanced prostate cancer often involves radiotherapy and androgen deprivation therapy; however, recent studies have suggested that radical prostatectomy (RP) is an acceptable primary treatment for locally advanced disease.

OBJECTIVE

To assess the technical feasibility of RP as a primary treatment for high-grade prostate cancer and to determine the short-term biochemical failure rates.

DESIGN AND INTERVENTION

This was a prospective analysis of consecutive patients who underwent RP with pelvic lymph node dissection for locally advanced prostate cancer between January 1998 and June 2004. Locally advanced prostate cancer was diagnosed if a patient had a Gleason score of ≥8 or a preoperative serum PSA level >15 ng/ml, or if his cancer was clinical stage T2b or worse. Medical records and patient interviews, including records from external hospitals, were used to compile follow-up information. The frequency of follow-up varied according to physician preference, but PSA level was always recorded and patient-reported continence data were obtained at 3 months' follow-up in all cases.

OUTCOME MEASURES

The primary end points were biochemical failure, length of hospital stay, and occurrence of complications.

RESULTS

Of the 281 eligible patients, 86 had received androgen-deprivation therapy or neoadjuvant chemotherapy, including etoposide and estramustine phosphate, docetaxel, granulocyte-macrophage colony-stimulating factor and thalidomide, antiandrogens alone, luteinizing hormone-releasing hormone agonist alone, and a combined androgen blockade. Only 14 patients received >6 months of treatment, and 64 patients had a median of 4 months of neo adjuvant androgen deprivation. The mean patient age at surgery was 61 years, and the mean follow-up period was 34 months. Pathologic examination revealed organ-confined disease in 11.7% of patients, extracapsular extension in 56.9%, seminal vesicle involvement in 23.1%, and positive lymph nodes in 8.9%. Overall, 46.6% of patients had organ-confined or specimen-confined disease, and 18.5% had positive margins. Mean postoperative hospitalization time was 2 days, with the Foley catheter left in place for a mean of 9 days. The postoperative complication rate, in the subset of 134 patients in whom it was prospectively evaluated, was 9.7%, compared with 6.9% in patients simultaneously undergoing RP for lower-grade disease. PSA level was undetectable in 70.4% of patients at their last follow-up examination, and the mean time to biochemical failure was 17.9 months. At a median of 24 months, 3.9% of patients had developed distant metastases and 1.1% had died of their disease. A further 2.8% of patients had died of other causes. The biopsy-proven local recurrence rate was 0.7%.

CONCLUSION

The authors conclude that RP is a feasible primary treatment for advanced prostate cancer, with short-term biochemical-recurrence-free survival rates similar to those seen following radiotherapy and androgen deprivation therapy, and complication rates similar to those seen in patients with less advanced prostate cancer.

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