The status of surgery in the management of high-risk prostate cancer

Abstract

Although the optimal treatment for patients with high-risk prostate cancer remains unclear, combined radiotherapy and androgen-deprivation therapy (ADT) has become the standard of care; however, more recently, this paradigm has been challenged. In contemporary surgical series, using a multimodal approach with primary radical prostatectomy and adjuvant radiotherapy, when appropriate, had comparable efficacy in patients with high-risk disease to radiotherapy in combination with ADT. Furthermore, perioperative and postoperative morbidity associated with radical prostatectomy seem to be similar in patients with low-risk, intermediate-risk, or high-risk prostate cancer. Importantly, downstaging and downgrading of a substantial proportion of tumours after surgery suggests that many patients might be overtreated using radiotherapy and ADT. Indeed, the potential benefits of surgery include the ability to obtain tissues that can provide accurate histopathological information and, therefore, guide further disease management, in addition to local control of disease, a potentially reduced risk of developing metastases, and avoidance of long-term ADT. Thus, patients with high-risk disease should be offered a choice of first-line treatments, including surgery. However, effective management of high-risk prostate cancer is likely to require a multimodal approach, including surgery, radiotherapy, and neoadjuvant and adjuvant ADT, although the optimal protocols remain to be determined.

Oncologic Outcome of Radical Prostatectomy as Monotherapy for Men with High-risk Prostate Cancer

“…In this series, of the several pathological parameters examined, the Gleason score, extracapsular extension, SVI, and SMS were identified as independent predictive factors of BR-free survival on multivariate analysis. The present outcomes are consistent with several previous studies [13][14][15][16][17][18]. For example, Ploussard et al [15] reported that the Gleason score ≥ 8, pathological stage ≥ pT3, positive SM, and lymph node involvement were independently associated with BR-free survival in 813 high-risk PCa patients who were treated with RP.…”

“…Despite being a comparatively shorter follow-up interval, these outcomes may be comparable to those in previous studies [5][6][7][13][14][15][16][17][18]. For example, Loeb et al [7] reported that at a median follow-up of 8 years in 175 high-risk PCa patients undergoing RP, BR, local recurrence, and metastatic dis- Radical Prostatectomy for High-risk Prostate Cancer 71 ease occurred in 29%, 3%, and 13%, respectively, and 6% died of PCa.…”

“…Accordingly, it has become attractive for patients with high-risk PCa, particularly younger men, to consider RP as an alternative option to EBRT combined with hormonal therapy. In fact, there have been several studies showing favorable cancer control by RP in men with high-risk PCa [6,7,[13][14][15][16][17][18]; however, these studies included some patients, albeit a very small proportion, who received additional therapy as either neoadjuvant or adjuvant setting. Considering these findings, in this study, we retrospectively assessed the prognostic outcomes in a total of 382 patients with high-risk PCa who underwent RP as monotherapy in order to address the significance of surgical treatment for patients with high-risk PCa.…”

“…Several previous studies suggested that these advantages of RP could be applied to patients with high-risk PCa as well, resulting in the achievement of favorable cancer control by combining other therapeutic modalities [6,7,[13][14][15][16][17][18]. For example, Meng et al [14] reported the 10-year outcomes from the CaPSURE database for men with high-risk PCa treated with RP, showing 95% cancer-specific survival and 80% overall survival.…”

Evaluation of prognostic factors after radical prostatectomy in pT3b prostate cancer patients in Japanese population

“…Recently, retrospective studies evaluating the surgical procedure as a part of multimodal treatments for the management of high-risk PCa have revealed that cancer-specific survival and overall survival rates after RP are equivalent to or much better than those observed after external-beam radiotherapy plus androgen-deprivation therapy (ADT) (2,3). Thus, RP in the treatment of high-risk PCa patients needs to be reevaluated.…”