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Abstract
High risk prostate cancer requires a multimodal approach to treatment. Surgery has played an increasing role for these patients although long-term follow-up and experience with neoadjuvant therapy, a basic tenet of cancer treatment, remains limited. Here we report our experience with neoadjuvant hormonal ablation followed by surgery and postoperative radiation with greater than 20-year follow-up. From 1990-2012, 82 patients with clinically organ-confined prostate cancer and 10 years median follow-up underwent multimodal therapy (MMT) consisting of neoadjuvant hormonal ablation followed by radical retropubic prostatectomy and postoperative radiation. High-risk prostate cancer was defined preoperatively as Gleason Score 8-10 or PSA>20. Patients with negative surgical margins were observed initially and treated with salvage XRT in the instance of recurrence. The MMT protocol was well tolerated in all 82 patients with no treatment-related discontinuation of therapy. Final surgical pathology revealed stage pT3-T4 in 58/82 (71%) and nodal involvement in 7/82 (9%). Distant metastatic disease was identified in 10/82 patients (12%). For patients undergoing MMT at 10, 15 and 20 years, cancer-specific survival was 78/82 (95%), 77 /82 (94%) and 77/82 (94%), overall survival was 68/82 (83%), 66/82 (80%) and 60/82 (73%), and biochemical recurrence was 61/82 (74%), 51/82 (62%) and 35/82 (43%). These findings establish the MMT protocol as an effective treatment strategy for high-risk prostate cancer with excellent long-term cancer-specific survival. Recurrence occurring primarily as a rising PSA as opposed to distant metastatic disease suggests limited morbidity as well among patients treated with this protocol.
Highlights
IntroductionUp to 50% of patients experienced recurrent disease following surgery underscoring a great need for better therapies in treating this disease
The management of high-risk prostate cancer remains challenging
With a favorable outcome for that patient, followed for over 20 years with no evidence of recurrence, this introduced multimodal therapy (MMT) as a new treatment paradigm for high-risk prostate cancer. While this protocol was an original concept in 1990, which for years others were reluctant to adopt and even felt was controversial, relatively recently there has been renewed interest in neoadjuvant therapy, given that post-operative recurrence following radical retropubic prostatectomy for high-risk prostate cancer has been associated with prostate cancer-related death in 80-90% of patients [1]
Summary
Up to 50% of patients experienced recurrent disease following surgery underscoring a great need for better therapies in treating this disease It is for this reason that we embarked on a new method of treatment for high risk prostate cancer. With a favorable outcome for that patient, followed for over 20 years with no evidence of recurrence, this introduced MMT as a new treatment paradigm for high-risk prostate cancer While this protocol was an original concept in 1990, which for years others were reluctant to adopt and even felt was controversial, relatively recently there has been renewed interest in neoadjuvant therapy, given that post-operative recurrence following radical retropubic prostatectomy for high-risk prostate cancer has been associated with prostate cancer-related death in 80-90% of patients [1]. As a result of renewed interest we felt obligated to report our experience with MMT
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