Athens, Greece (UroToday.com) In this debate, Dr. Dillioğlugil debated to not use radical prostatectomy in the oligometastatic patient. When analyzing the meta-analysis evaluating the impact of the site of metastasis on overall survival in men with castration-resistant prostate cancer,1 including almost 9,000 men, it was sown that there is successively increased lethality for lung and liver metastases compared with bone and non-visceral involvement (Figure 1).
Figure 1 – Site of metastasis in prostate cancer predicts overall survival:
This means that not all metastases are created equal. There are many different definitions of oligometastatic prostate cancer.2 Even when assessing the results of the advanced prostate cancer consensus conference (APCCC) in 2017, no consensus could be reached regarding this definition.3 When looking at a study that assessed the impact of radical prostatectomy in men with metastatic castrate-resistant prostate cancer (mCRPC), it seemed that men with mCRPC who previously had radical prostatectomy had similar survival compared to men who did not undergo surgery.4 These data, according to Dr. Dillioğlugil, do not support treating the primary tumor.
According to Dr. Dillioğlugil, the retrospective studies that support treating the primary tumor in the setting of metastatic disease have significant biases and their results should not be considered. For instance, in the NCDB analysis by Loppenberg et al.5, patients who had the local treatment and demonstrated a survival advantage, were considerably younger, had lower PSA values, less poorly differentiated tumors, less clinically advanced disease, and lower comorbidity scores, compared to the patients who did not receive local treatment. These could explain the differences that were witnessed in this study.
In conclusion, Dr. Dillioğlugil, believes that men with metastatic prostate cancer at diagnosis benefit from local therapy in terms of overall survival. However, the patients that benefit the most are those with a relatively low tumor risk and volume, (as was shown in the landmark STAMPEDE trial6), and in general in good health. Referring patients to the treatment of the primary tumor with radical prostatectomy, should still be considered experimental, and conducted in the setting of a clinical trial. Once we receive the results of the awaited randomized controlled trials that are specifically assessing this question, we will be able to make a more definitive decision regarding the efficacy of this treatment.
Presented by: Özdal Dillioğlugil, MD, Professor, Department of Urology, Kocaeli University School of Medicine, Kocaeli, Turkey
Written by: Hanan Goldberg, MD, Urology Department, SUNY Upstate Medical University, Syracuse, NY, USA, Twitter: @GoldbergHanan at the 39th Congress of the Société Internationale d'Urologie, SIU 2019, #SIUWorld #SIU2019, October 17-20, 2019, Athens, Greece
References:
4. Halabi S, Vogelzang NJ, Ou SS, Small EJ. The impact of prior radical prostatectomy in men with metastatic castration recurrent prostate cancer: a pooled analysis of 9 Cancer and Leukemia Group B Trials. The Journal of urology 2007; 177(2): 531-4.
Read the Opposing Debate: SIU 2019: Debate: Does Radical Prostatectomy Have a Role in the Management of Oligomets? Pro