EAU 2019: The Urologist’s Perspective on Surgery for Prostate Cancer
The first point discussed is that the role of radical prostatectomy as a first treatment option in advanced prostate cancer will increase. In a recent study assessing the treatment option of patients with Gleason 9-10 disease, it was shown that brachytherapy + external beam radiotherapy + hormonal therapy had a significant better cancer-specific survival and metastasis-free survival than radical prostatectomy. 1 In contrast, another study compared radical prostatectomy + adjuvant radiotherapy to radiotherapy + hormonal therapy in men >65 years old from the SEER-Medicare database with advanced prostate cancer. 2 The results demonstrated that radical prostatectomy +adjuvant radiotherapy was more effective but had a worse functional outcome. Due to these discrepancies we need to await the much anticipated results of the SPCG 15 trial, which is a prospective, open randomized phase III surgical trial seeking to study whether radical prostatectomy (with or without the combination of external radiation) improves prostate cancer-specific survival in comparison with primary radiation treatment and hormonal treatment among patients diagnosed with locally advanced (T3) prostate cancer.
Next, Dr. Graefen mentioned that neoadjuvant androgen deprivation therapy (ADT) before surgery should be explored again. Recent data have shown that there might be a favorable role for neoadjuvant ADT in high risk/locally advanced prostate cancer patients. 3
The role of cytoreductive radical prostatectomy was the next topic discussed. The recently published STAMPEDE trial demonstrated that local treatment (in the form of radiotherapy) of the primary tumor in low metastatic burden disease is the new standard with very favorable results. 4 Urologists can use this trial as an argument that radical prostatectomy can replace radiotherapy and have at least equivalent results, although we still require specific trials to prove this.
Dr. Graefen concluded his talk and moved on to discuss the use of salvage radical prostatectomy. He believes that salvage radical prostatectomy will be extensively explored after the failure of focal therapy, but the oncological and functional outcomes of this procedure will be worse. However, salvage pelvic lymph node dissection will become an integral part of management in local recurrence with overall good results. It is critical to identify the correct patients when utilizing the option of salvage therapy. PSMA-PET will be used as the diagnostic imaging of choice to identify suspicious nodules and make sure the surgeon knows what nodes he needs to respect.
Presented by: Markus Graefen, Professor, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.
References:
1. Kishan AU. et al. JAMA 2018. Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy With Brachytherapy Boost and Disease Progression and Mortality in Patients With Gleason Score 9-10 Prostate Cancer. JAMA. 2018;319(9):896-905. doi:10.1001/jama.2018.0587. https://jamanetwork.com/journals/jama/fullarticle/2673969
2. Jang TL. et al. Cancer 2018. Comparative effectiveness of radical prostatectomy with adjuvant radiotherapy versus radiotherapy plus androgen deprivation therapy for men with advanced prostate cancer. Cancer. 2018 Oct 15;124(20):4010-4022. doi: 10.1002/cncr.31726. Epub 2018 Sep 25. https://www.ncbi.nlm.nih.gov/pubmed/302529323.
3. Tosco L. et al. Prostate Cancer Prostatic Dis. 2017. The survival impact of neoadjuvant hormonal therapy before radical prostatectomy for treatment of high-risk prostate cancer. Prostate Cancer Prostatic Dis. 2017 Dec;20(4):407-412. doi: 10.1038/pcan.2017.29. Epub 2017 May 9. https://www.ncbi.nlm.nih.gov/pubmed/28485390
4. Parker C. et al. Lancet 2018. Radiotherapy to the primary tumour for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial. Published: October 21, 2018. DOI: https://doi.org/10.1016/S0140-6736(18)32486-3. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32486-3/fulltext