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Achieving optimal outcomes after radical prostatectomy
P.R. Carroll / Urologic Oncology: Seminars and Original Investigations 23 (2005) 459 – 466
461
Commentary This study supports the findings of at least one other contemporary study showing an increase in the use of luteinizing hormone-releasing hormone (LH-RH) agonists in men with prostate cancer [1]. Some of this increased use is likely motivated by the publication of several randomized trials showing a benefit of the use of such agents in conjunction with external beam radiation in men with intermediate and high-risk disease. Interestingly, it appears that only 20% of patients who received radiation in this study were treated with LH-RH agonists. This use may also be motivated by the findings of some studies showing a benefit to the early use of LH-RH agonists in those patients with high-risk disease, who either had a relapse or are at high risk for relapsing after primary therapy. The use of LH-RH agonists in low-risk disease (pT1/2, Gleason 2/3, serum prostate-specific antigen ⬍10 ng/ml), either as neoadjuvant, adjuvant, or primary therapy, is disturbing given the protracted natural history of the disease and the fact that no randomized trial published to date supports the routine use of such therapy. However, it is noteworthy that the inappropriate use of other forms of therapy (e.g., surgery, external radiation, brachytherapy) might similarly be used in patients who may not benefit from its immediate use. Finally, the use of LH-RH agonists as primary therapy (i.e., not used in conjunction with others forms of therapy) in men with nonmetastatic but high-risk disease requires more formal study to note its side effects, durability, and effect on disease-free and overall survival compared to other forms of primary treatment. doi:10.1016/j.urolonc.2005.08.016 Peter R. Carroll, M.D.
Reference [1] Cooperberg MR, Small EJ, D’Amico A, et al. The evolving role of androgen deprivation therapy in the management of prostate cancer. Minerva Urol Nefrol 2003;55:219 –38.
Achieving optimal outcomes after radical prostatectomy. Saranchuk JW, Kattan MW, Elkin E, Touijer AK, Scardino PT, Eastham JA, Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY. J Clin Oncol 2005;23:4146 –51 Purpose: The most favorable outcome that can be achieved after radical prostatectomy is complete tumor resection without recurrence and full recovery of continence and potency. Risks of erectile dysfunction, incontinence, and disease recurrence are well described, but in isolation, do not adequately inform patients of the possibility of becoming cancer-free while at the same time returning to their preoperative functional state. We sought to determine the frequency of optimal outcomes after radical prostatectomy and the time to such outcomes. Patients and Methods: Patients who underwent radical prostatectomy performed at a tertiary referral center between July 1998 and July 2003 for clinical stage T1 to T3 prostate cancer were identified. Patients were excluded if they were incontinent or impotent preoperatively, or if they had received radiotherapy or neoadjuvant androgen deprivation therapy previously. Six hundred forty-seven patients were analyzed for time to recovery of full continence and potency without cancer recurrence after surgery. Optimal outcome probability was calculated with a Markov state transition model to simulate clinical outcomes in the first 4 years following radical prostatectomy. Results: Mean patient age was 58 years, and mean pretreatment prostate-specific antigen was 6.9 ng/mL. Cancer-free status with full continence and potency was achieved in 30% of men at 12 months, 42% at 24 months, 47% at 36 months, and 53% at 48 months postoperatively. Conclusion: Optimal outcomes after radical prostatectomy can be achieved in a small majority of cases. Time to full recovery is primarily dictated by recovery of erectile function. This information is helpful for patients interested in their chances of returning to their preoperative functional state. Commentary The study by Saranchuk and colleagues is an important and insightful one performed by excellent and well-regarded surgeons. It serves as one of the few well-documented, clinical benchmarks in the field of radical prostatectomy. Favorable outcomes after surgery, or any other treatment, must be assessed in multiple dimensions, which include the obvious ones such as overall and disease-free survival, but also those that focus on health-related quality of life. These latter dimensions are especially important in prostate cancer, which most often has a protracted natural history. Of patients undergoing radical prostatectomy, 53% had an optimal outcome at 45 months after surgery (disease-free, continent, and potent). Failure to achieve an optimal outcome was dominated by failure to regain potency because 93% of patients were continent and 88% disease-free at 2 and 5 years after surgery, respectively. This study clearly shows that better efforts at preserving potency either by modifying surgical technique or through innovative postoperative treatment regimens are needed for those patients undergoing surgery and likely other forms of prostate cancer treatment. doi:10.1016/j.urolonc.2005.08.018 Peter R. Carroll, M.D.
461
Commentary This study supports the findings of at least one other contemporary study showing an increase in the use of luteinizing hormone-releasing hormone (LH-RH) agonists in men with prostate cancer [1]. Some of this increased use is likely motivated by the publication of several randomized trials showing a benefit of the use of such agents in conjunction with external beam radiation in men with intermediate and high-risk disease. Interestingly, it appears that only 20% of patients who received radiation in this study were treated with LH-RH agonists. This use may also be motivated by the findings of some studies showing a benefit to the early use of LH-RH agonists in those patients with high-risk disease, who either had a relapse or are at high risk for relapsing after primary therapy. The use of LH-RH agonists in low-risk disease (pT1/2, Gleason 2/3, serum prostate-specific antigen ⬍10 ng/ml), either as neoadjuvant, adjuvant, or primary therapy, is disturbing given the protracted natural history of the disease and the fact that no randomized trial published to date supports the routine use of such therapy. However, it is noteworthy that the inappropriate use of other forms of therapy (e.g., surgery, external radiation, brachytherapy) might similarly be used in patients who may not benefit from its immediate use. Finally, the use of LH-RH agonists as primary therapy (i.e., not used in conjunction with others forms of therapy) in men with nonmetastatic but high-risk disease requires more formal study to note its side effects, durability, and effect on disease-free and overall survival compared to other forms of primary treatment. doi:10.1016/j.urolonc.2005.08.016 Peter R. Carroll, M.D.
Reference [1] Cooperberg MR, Small EJ, D’Amico A, et al. The evolving role of androgen deprivation therapy in the management of prostate cancer. Minerva Urol Nefrol 2003;55:219 –38.
Achieving optimal outcomes after radical prostatectomy. Saranchuk JW, Kattan MW, Elkin E, Touijer AK, Scardino PT, Eastham JA, Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY. J Clin Oncol 2005;23:4146 –51 Purpose: The most favorable outcome that can be achieved after radical prostatectomy is complete tumor resection without recurrence and full recovery of continence and potency. Risks of erectile dysfunction, incontinence, and disease recurrence are well described, but in isolation, do not adequately inform patients of the possibility of becoming cancer-free while at the same time returning to their preoperative functional state. We sought to determine the frequency of optimal outcomes after radical prostatectomy and the time to such outcomes. Patients and Methods: Patients who underwent radical prostatectomy performed at a tertiary referral center between July 1998 and July 2003 for clinical stage T1 to T3 prostate cancer were identified. Patients were excluded if they were incontinent or impotent preoperatively, or if they had received radiotherapy or neoadjuvant androgen deprivation therapy previously. Six hundred forty-seven patients were analyzed for time to recovery of full continence and potency without cancer recurrence after surgery. Optimal outcome probability was calculated with a Markov state transition model to simulate clinical outcomes in the first 4 years following radical prostatectomy. Results: Mean patient age was 58 years, and mean pretreatment prostate-specific antigen was 6.9 ng/mL. Cancer-free status with full continence and potency was achieved in 30% of men at 12 months, 42% at 24 months, 47% at 36 months, and 53% at 48 months postoperatively. Conclusion: Optimal outcomes after radical prostatectomy can be achieved in a small majority of cases. Time to full recovery is primarily dictated by recovery of erectile function. This information is helpful for patients interested in their chances of returning to their preoperative functional state. Commentary The study by Saranchuk and colleagues is an important and insightful one performed by excellent and well-regarded surgeons. It serves as one of the few well-documented, clinical benchmarks in the field of radical prostatectomy. Favorable outcomes after surgery, or any other treatment, must be assessed in multiple dimensions, which include the obvious ones such as overall and disease-free survival, but also those that focus on health-related quality of life. These latter dimensions are especially important in prostate cancer, which most often has a protracted natural history. Of patients undergoing radical prostatectomy, 53% had an optimal outcome at 45 months after surgery (disease-free, continent, and potent). Failure to achieve an optimal outcome was dominated by failure to regain potency because 93% of patients were continent and 88% disease-free at 2 and 5 years after surgery, respectively. This study clearly shows that better efforts at preserving potency either by modifying surgical technique or through innovative postoperative treatment regimens are needed for those patients undergoing surgery and likely other forms of prostate cancer treatment. doi:10.1016/j.urolonc.2005.08.018 Peter R. Carroll, M.D.