BERKELEY, CA (UroToday.com) - Determining the optimal role of surgical intervention in the treatment of prostate cancer has been a major focus at Memorial Sloan Kettering Cancer Center (MSKCC) for many years.
Over the past decade we have made an institutional effort to recommend active surveillance (AS) to patients with low-risk, low-volume disease after immediate repeat biopsy.1 Such patients may be able to significantly delay or perhaps entirely avoid surgical intervention. Over the same time period there has been increased recognition that surgery may be the preferred initial treatment for men with higher risk disease.2T hese findings, as well as evidence from trials such as Prostate Cancer Intervention Versus Observation Trial (PIVOT) which reported results at the 2011 AUA annual meeting, have begun to demonstrate that the benefit of surgery may be greatest in those with higher risk disease.
These observations have developed during the same time in which there has been a rapid expansion in the use of robotic assisted laparoscopic prostatectomy (RALP). Most often, RALP has been applied to those patients with low-risk prostate cancer.3,4 Our study demonstrates that this does not necessarily need to be, nor should it be the case. At MSKCC we have seen a significant decline in the number of low-risk men undergoing RALP, while at the same time there has been a dramatic increase in the number of RALPs performed.
The increased risk profile of patients receiving RP at MSKCC has not been limited to RALP.7 There has been a similar rise in the patient risk profile for open or pure laparoscopic surgery as well. Importantly, this increased preoperative patient risk profile is manifested in the pathologic finding at the time of surgery. A correspondingly higher proportion of patients are found to have extracapsular disease, proving that these changes are not merely a reflection of changes in biopsy Gleason scoring as some have suggested.8 The reasons for these changes have not been fully elucidated in this study but are likely in part due to the increasing number of men electing active surveillance. As the number of low-risk men electing surgery declines the remaining pool of surgical patients is at higher risk - what we referred to as a “reverse stage shift.” This is an important observation for surgeons as it may influence key aspects of the surgical technique including decisions regarding lymph node dissection and nerve sparing techniques.
When surgery, particularly RALP, is performed on higher risk patients, the focus must remain on the oncologic principles of proper cancer surgery with the goal of disease eradication. It is concerning that studies have shown that five times as many patients receive lymph node dissections with open compared to minimally invasive surgery.5 Current NCCN guidelines recommend that lymph node dissections be performed on patients with a preoperative nomogram risk for lymph node invasion that is equal to or greater than 2%. This accounts for 70% of patients currently undergoing surgery at our institution. When lymph node dissections are done with robotic assistance, the outcomes may be and should be, if properly performed, similar to those of open or pure laparoscopic technique.6 Additionally, surgical margin results in these high-risk patients should not differ because of surgical approach or nerve sparing technique.
Identification of the precise population of patients that optimally benefit from surgical intervention remains an evolving process. It is becoming increasingly evident however that low-risk patients can be considered for alternate treatment strategies including active surveillance. Intermediate and high-risk patients may benefit the most from surgical intervention providing that it is properly focused and performed.
References:
- Berglund, R. K., Masterson, T. A., Vora, K. C. et al.: Pathological upgrading and up staging with immediate repeat biopsy in patients eligible for active surveillance. J Urol, 180: 1964, 2008
- Zelefsky, M. J., Eastham, J. A., Cronin, A. M. et al.: Metastasis after radical prostatectomy or external beam radiotherapy for patients with clinically localized prostate cancer: a comparison of clinical cohorts adjusted for case mix. J Clin Oncol, 28: 1508
- Barbash, G. I., Glied, S. A.: New technology and health care costs--the case of robot-assisted surgery. N Engl J Med, 363: 701
- Lowrance*, W., Affiliations, New York, N. et al.: Contemporary open and robotic radical prostatectomy practice patterns among United States urologists. J Urol, 185: e136, 2011
- Feifer, A. H., Elkin, E. B., Lowrance, W. T. et al.: Temporal trends and predictors of pelvic lymph node dissection in open or minimally invasive radical prostatectomy. Cancer
- Jonathan L. Silberstein, A. J. V., Nicholas E. Power, Raul O. Parra, Jonathan A. Coleman, Rodrigo Pinochet, Karim A. Touijer, Peter T. Scardino, James A. Eastham and Vincent P. Laudone: Uniform anatomic template for pelvic lymph node dissection during radical prostatectomy: Comparison of open, laparoscopic and robot-assisted procedures. J Urol, 185: e264, 2011
- Silberstein, J. L., Vickers, A. J., Power, N. E. et al.: Reverse stage shift at a tertiary care center: Escalating Risk in Men Undergoing Radical Prostatectomy. Cancer
- Billis, A., Guimaraes, M. S., Freitas, L. L. et al.: The impact of the 2005 international society of urological pathology consensus conference on standard Gleason grading of prostatic carcinoma in needle biopsies. J Urol, 180: 548, 2008
Written by:
Vincent P. Laudone, MD and Jonathan Silberstein, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
UroToday.com Prostate Cancer Section