Oncologic Outcomes Of Radical Prostatectomy Research Articles

P070 Oncological outcomes of radical prostatectomy for high-risk prostate cancer

P070 Oncological outcomes of radical prostatectomy for high-risk prostate cancer

Long-term oncologic outcomes of neoadjuvant chemohormonal therapy followed by radical prostatectomy for patients with clinically localized, high-risk prostate cancer.

153 Background: To determine long-term oncologic outcomes of radical prostatectomy (RP) after neoadjuvant chemo-hormonal therapy for clinically localized, high-risk prostate cancer. Methods: In this phase II multicenter trial of patients with high-risk prostate cancer (prostate-specific antigen greater than 20ng/ml, Gleason greater than or equal to 8, or clinical stage greater than or equal to T3), androgen deprivation therapy (goserelin acetate depot) and paclitaxel, carboplatin and estramustine were administered prior to RP. We report the long-term oncologic outcomes of these patients and compared them to a contemporary cohort who met oncologic inclusion criteria but received RP only. Results: Thirty four patients were enrolled in this study and followed for a median of 13.1 years. Within 10 years most patients experienced biochemical recurrence (BCR-free probability= 22%; 95% CI 10%, 37%). However the probability of disease-specific survival at 10 years was 84% (95% CI 66%, 93%) and overall survival was 78% (95% CI 60%, 89%). The chemohormonal therapy group had higher-risk features than the comparison group (N=123 patients) with an almost doubled risk of calculated preoperative 5-year BCR (69% vs 36%, p<0.0001). After adjusting for these imbalances the CHT group had trends toward improvement in BCR (0.76, 95% CI 0.43, 1.34; p=0.3) and metastasis free survival (0.55, 95% CI 0.24, 1.29; p=.2) although these were not significant. Conclusions: Neoadjuvant chemohormonal therapy followed by RP was associated with lower observed rates of BCR and metastasis compared to a prostatectomy only group; however these results were not significant. Because this treatment strategy has known harms and unproven benefit, this strategy should only be instituted in the setting of a clinical trial.

Oncologic outcomes of radical prostatectomy with neoadjuvant LHRH agonist/estramustine and radiotherapy with neoadjuvant hormonal therapy for high-risk prostate cancer.

259 Background: To date, the different treatment modalities for high-risk prostate cancer (Pca) have not been compared in any sufficiently large-scale, prospective, randomized clinical trial. We used propensity-score matching analysis to compare the oncological outcomes of high-risk prostate cancer between patients treated with radical prostatectomy (RP) and those treated with radiation therapy (RT). Methods: We studied 216 patients who received neoadjuvant therapy followed by RP (RP cohort) and 81 patients who received neoadjuvant androgen-deprivation therapy (ADT) followed by RT (RT cohort). The RP cohort received a luteinizing hormone-releasing hormone agonist and estramustine phosphate (280 mg/day) for 6 months prior to RP. The RT cohort received ADT for at least 6 months prior to RT using a 3-dimensional conformal radiotherapy technique. The total radiation dose was 70–76 Gy administered at 2 Gy/fraction. Results: Propensity-score matching identified 78 matched pairs of patients. The 3-year overall survival (OS) rates were 98.3% and 92.1% in the RP and RT groups, respectively (P = 0.156). The 3-year biochemical recurrence-free survival rates were 86.4% and 89.4% in the RP and RT groups, respectively (P = 0.878). Conclusions: Our study findings may suggest almost identical cancer control of RP and RT with appropriate neoadjuvant therapy in high-risk Pca. Therefore, issues of health-related quality of life may have important impact on decision making of treatment in high-risk Pca.

Prostatectomy at high- versus low-volume centers: A decision analysis.

175 Background: Greater experience improves the oncological outcomes of radical prostatectomy (RP) for prostate cancer; however, it is not clear whether referring patients to a high volume center (HVC) for RP is cost effective. This study aims to investigate this question. Methods: We assumed status quo wherein 50% of RPs occur at an HVC and the other 50% occur in less experienced hands (scenario one or “referent scenario”). We then modeled increasing the share of RPs at an HVC by 10% increments (scenarios two, three, and four). Assuming that a lower probability of prostate-specific antigen recurrence (PSAR) is the only advantage of more experienced surgeons, the savings that would result from fewer recurrences, avoidance of salvage radiation therapy (SRT) and management of fewer men with metastatic cancer were calculated. A breakeven analysis using incremental referral costs and a cost effectiveness analysis (CEA), adding the incremental effectiveness measured in years in the no evidence disease (NED) state and the expected difference in overall survival (OS), were performed to determine the breakeven point and the range of the maximum referral costs to an HVC. Results: At five years 8.2% of patients will experience PSAR in the referent scenario versus 6.9% in scenario four. More patients would have PSAR in a low-volume center (LVC) setting after RP. Assuming 37% of these patients would receive SRT and those who will develop metastatic disease will receive treatment, this incremental cost discounted at 3% is $265, $456, and $609 per RP for scenario four at 5, 10, and 15 years, respectively. These figures will be $177, $309, and $415 and $86, $152, and $205 at 5, 10, and 15 years for scenarios three and two, repectively. Breakeven analysis shows that over 15 years, savings from referring patients to an HVC would offset up to $2,000 per RP in initial referral costs. This figure remains stable for scenarios two, three, and four. CEA shows that the range for maximum costs of referral assuming a willingness to pay of $50,000 per year are $4,300 to $23,700 at 15 years of follow up. Lower PSAR rates for LVCs, or using the lower SRT or treatment of metastasis costs result in smaller values for breakeven referral costs. Conclusions: Performing RPs at an HVC is associated with significant savings that offset the initial referral costs and may be cost effective beyond the breakeven point.

Changes in Indications and Oncological Outcomes of Radical Prostatectomy After 2000—Data From 1268 Japanese Patients Treated with Radical Prostatectomy Between 2000 and 2009

The aim of the study was to characterize trends in indications for and oncological outcomes of radical prostatectomy after 2000. Data from 1268 patients undergoing radical prostatectomy without neoadjuvant therapy between 2000 and 2009 at four urological centers in Japan were retrospectively reviewed. Changes in age at radical prostatectomy, prostate-specific antigen level, biopsy Gleason score, clinical T stage, D'Amico risk classification, organ-confined disease and tumor volume in surgical specimens were analyzed over time. The median age at radical prostatectomy decreased from 68 years in 2000-2 to 65 years in 2009 (P < 0.001). Approximately 63.3% of patients were ≥65 years old, and 31.4% of patients were ≥70 years old during the whole study period. The median prostate-specific antigen level decreased from 8.61 ng/ml in 2000-2 to 6.90 ng/ml in 2009 (P < 0.001). The rate of organ-confined disease increased from 52.8% in 2000-2 to 72.5% in 2009 (P = 0.004). The median tumor volume decreased from 1.70 cc in 2000-2 to 1.28 cc in 2009 (P = 0.017). The proportion of biopsy Gleason score 7 increased from 40.6% in 2000-2 to 60.1% in 2009 (P < 0.001), and the proportion of the intermediate-risk group increased from 39.5% in 2000-2 to 59.5% in 2009 (P < 0.001). Age at radical prostatectomy for men with localized prostate cancer was higher in Japan than in the USA or Europe. Prostate-specific antigen, non-organ-confined disease and tumor volume decreased during the study period, whereas Gleason score 7 and intermediate-risk disease increased during the study period. This information enables comparison of outcomes between various treatments, between various geographic regions and between various time periods.

Radical prostatectomy represents an effective treatment in patients with specimen‐confined high pathological Gleason score prostate cancer

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: To date, only a few studies have addressed the long-term oncological outcomes of radical prostatectomy (RP) in patients with pathological Gleason score ≥ 8 prostate cancer. According to these reports, some individuals with pathological Gleason score ≥ 8 may benefit from RP, with cancer-control outcomes comparable with those of patients with low- and intermediate-risk prostate cancer. The presence of pathological Gleason score 8-10 represents a poor prognostic factor in the outcome of men with prostate cancer. However, in patients with specimen-confined disease, RP and bilateral PLND provided long-term cancer-control outcomes similar to those of patients with more favourable disease characteristics. To evaluate the outcomes of patients with pathological Gleason score 8-10 prostate cancer subjected to radical prostatectomy (RP). To determine the prognostic factors associated with cancer-specific survival (CSS) in this subset of patients. The study included 580 consecutive patients with pathological Gleason sum 8-10 prostate cancer treated with RP and pelvic lymph node dissection (PLND) at a single European institution between July 1988 and April 2010. All patients had detailed pathological and follow-up data. Pathological Gleason score was determined by a single expert genitourinary pathologist. Biochemical recurrence (BCR) was defined PSA concentration of ≥ 0.2 ng/mL and rising. Kaplan-Meier plots were used to graphically explore BCR-free survival as well as CSS and overall survival (OS) rates. Moreover, univariable and multivariable Cox regression models were fitted to test the predictors of CSS. The mean (median, range) age at surgery was 66.1 (66.4, 41-85) years. The mean (median, range) total PSA concentration was 29.6 (11.1, 0.5-1710) ng/mL. Pathological Gleason score was 8 in 238 (41.0%), 9 in 330 (56.9%) and 10 in 12 (2.1%) patients. Overall, 119 (20.5%), 124 (21.4%), 281 (48.4%) and 56 (9.7%) patients had pT2, pT3a, pT3b and pT4 prostate cancer, respectively. Overall, 275 (47.4%) had LN invasion, while 150 (25.1%) patients had specimen-confined disease (defined as pT2cR0 pN0 or pT3aR0 pN0 prostate cancer). The mean (median, range) follow-up was 53 (47, 1-226) months. At 5 and 10 years after RP, BCR-free survival was 76.7% and 49.6%, respectively. Similarly, the 5- and 10-year CSS rates were 87.3% and 69.5%, respectively. Patients with specimen-confined disease (P < 0.001) and patients with negative LNs (P = 0.012) had significantly better CSS rates than their counterparts with less favourable pathological characteristics. In multivariable Cox regression models, only the presence of specimen-confined disease achieved independent predictor status (P = 0.001). Presence of high Gleason score at RP represents a poor prognostic factor in the outcome of patients with prostate cancer. However, RP provides excellent long-term cancer control outcomes in the subset of patients with specimen-confined disease.