surgery for localised, locally advanced and high risk prostate cancer
TRANSCRIPT
Steven Joniau, MD, PhD
University Hospitals Leuven
Leuven
Belgium
Surgery for localized, locally advanced and
high risk prostate cancer
117,328 patients with prostate cancer
26,410 low risk (22.5%)
cT1-T2, PSA <10 ng/ml AND Gleason 2-6
26,611 intermediate risk (22.7%)
cT1-T2 AND PSA 10 - <20 OR Gleason 7
30,159 high risk (25.7%)
cT3 or PSA 20-50 or Gleason 8-10
Non-curatively treated
Rider JR et al. Eur Urol 2012 2
Who dies of PCa? Natural evolution of non-curatively treated PCa
10%
20%
35-40%
Rider JR et al. Eur Urol 2012
All ages <65 years 65-75 years >75 years
Prostate cancer Cardiovascular Other
Lo
w r
isk
M
ed
ium
ris
k
Hig
h r
isk
Who dies of PCa?
Natural evolution of non-curatively treated PCa
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Complete removal of the prostate, seminal vesicles, and pelvic lymph nodes (when necessary)
• With minimal perioperative morbidity, no blood transfusions, and early return to normal activities
• No positive surgical margins
• No long-term loss of continence or potency
Goals of modern radical prostatectomy (RP)
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PIVOT Trial
PSA detected
RP vs observation for localised PCa
RP did not significantly reduce all-cause or PCa-specific mortality as compared
with observation
Wilt TJ et al. N Engl J Med 2012;367:203-13
PCa-specific mortality
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PCa specific mortality
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Overall mortality
Intermediate risk PCa
Wilt TJ et al. N Engl J Med 2012;367:203-13
Briganti A, Spahn M, Joniau S et al. for EMPaCT Eur Urol 2013
Only men ≤ 59 years old had higher risk of PCa-related
death than death-related to other causes
10%
<10%
Prostate cancer Other
MORTALITY RATES FOR SURGICALLY TREATED
HIGH-RISK PCa
Cooperberg M, et al. AUA 2015 – Data from CAPSURE
Which treatment for which cancer?
Up untill 2007, Low-risk PCa was too often actively treated,
while high-risk PCa was too often undertreated 10
Cooperberg M, et al. AUA 2015 – Data from CAPSURE 11
After 2007, Low-risk PCa was more often treated with AS/WW,
while high-risk PCa was more often actively treated!!!
Which treatment for which cancer?
Cumulative incidence function estimates of cancer
specific and other cause mortality survival curves
(n=34 515), stratified according to treatment type.
Sooriakumaran P et al. BMJ 2014;348:bmj.g1502
M+ or N+ or T4 or
PSA>50 Low Intermediate High
RP
RT
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Sooriakumaran P et al. BMJ 2014;348:bmj.g1502
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Cumulative incidence function estimates of cancer
specific and other cause mortality survival curves
(n=34 515), stratified according to treatment type.
- Retrospective analysis of data from the Norwegian Prostate Cancer Registry, 2004-2005
- 3486 patients, RP (n = 895), EBRT +/- ADT (n = 1339), or no local treatment (n = 1252)
- Clinical stage T1-T3, PSA ≤100 ng/ml, D’Amico risk group stratification
- Comparison of active local treatment (RP, RAD) versus no active local treatment (NoLocTrt)
PCa mortality
Other cause mortality
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HIGH-RISK
• NO difference in positive surgical margins
• NO difference in incontinence
• SMALL difference in erectile dysfunction in favor of RALP
The changing role of surgery
• Properly performed, RP is a highly effective treatment
for high-risk prostate cancer in men with a sufficiently long life expectancy to justify the risks
• Outcomes of RP – cancer control, peri-op complications, and long-term urinary and sexual function – are directly related to the skill and experience of the surgeon, but not to the technology used (open v. robot-assisted)
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