Role of radical prostatectomy in metastatic prostate cancer: A review.

[pjoshea13]

New paper below.

"... the role of radical prostatectomy (RP) in multimodal treatment for locally advanced prostate cancer is expanding. As a result, there is interest in investigating the potential benefit of cytoreductive RP in mPCa."

"Cytoreductive prostatectomy in mPCa is a feasible procedure that may improve outcomes for men when combined with multimodal management. Preclinical, translational, and retrospective evidence supports local therapy for metastatic disease. However, currently, evidence is limited and is subject to bias. The results of ongoing prospective randomized trials are required before incorporating this therapeutic strategy into clinical practice."

-Patrick

ncbi.nlm.nih.gov/pubmed/281...

Urol Oncol. 2017 Feb 9. pii: S1078-1439(17)30001-7. doi: 10.1016/j.urolonc.2017.01.001. [Epub ahead of print]

Role of radical prostatectomy in metastatic prostate cancer: A review.

Metcalfe MJ1, Smaldone MC2, Lin DW3, Aparicio AM4, Chapin BF5.

Author information

1Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address: [e-mail].

2Department of Urology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA.

3Department of Urology, University of Washington, Seattle, WA.

4Department of Genitourinary Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.

5Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX.

Abstract

CONTEXT:

Recent demonstration of efficacy with the use of chemohormonal therapy for men with metastatic prostate cancer (mPCa) has expanded the therapeutic options for these patients. Furthermore, multimodal therapy to treat systemic disease in the context of locoregional control has gained increasing interest. Concomitantly, the role of radical prostatectomy (RP) in multimodal treatment for locally advanced prostate cancer is expanding. As a result, there is interest in investigating the potential benefit of cytoreductive RP in mPCa.

OBJECTIVE:

To review the literature regarding the role of cytoreductive prostatectomy in the setting of mPCa.

EVIDENCE ACQUISITION:

MEDLINE and PubMed electronic databases were queried for English language articles related to patients with mPCa who underwent RP from January 1990 to June 2016. Key words used in our search included cytoreductive prostatectomy, radical prostatectomy, and metastatic prostate cancer. Preclinical, retrospective, and prospective studies were included.

EVIDENCE SYNTHESIS:

There are no published randomized control trials examining the role of cytoreduction in mPCa. Local symptoms are high in mPCa and often provide a necessity for palliative procedures with the impact on oncologic outcomes being uncertain. Recently, preclinical and retrospective population-based data suggest a benefit from treatment of the primary tumor in metastatic disease. Potential mechanisms mediating this benefit include prevention of symptomatic local progression and modulation of disease biology, resulting in an improvement in progression-free and overall survival. Current literature supports the feasibility of cytoreductive prostatectomy as it is associated with acceptable side effects that are comparable to RP for high-risk localized disease. In aggregate, these data compel prospective evaluation of the hypothesis that cytoreductive prostatectomy improves the outcome of men with mPCa.

CONCLUSIONS:

Cytoreductive prostatectomy in mPCa is a feasible procedure that may improve outcomes for men when combined with multimodal management. Preclinical, translational, and retrospective evidence supports local therapy for metastatic disease. However, currently, evidence is limited and is subject to bias. The results of ongoing prospective randomized trials are required before incorporating this therapeutic strategy into clinical practice.

Copyright © 2017 Elsevier Inc. All rights reserved.

KEYWORDS:

Cytoreduction; Cytoreductive radical prostatectomy; Local treatment; Prostate cancer; Radical prostatectomy; Surgery in metastatic; Surgery in systemic; Treatment of primary tumor

PMID: 28190749 DOI: 10.1016/j.urolonc.2017.01.001

[PubMed - as supplied by publisher]

[AlanMeyer]

The authors state:

"... currently, evidence is limited and is subject to bias. The results of ongoing prospective randomized trials are required before incorporating this therapeutic strategy into clinical practice."

I look at that conclusion and I think: If this were a question of taking a pill that was known to have no significant side effects, maybe I'd forgo waiting for the trial and go ahead and take the pill. But it's not like that. It's a question of choosing major surgery with all the usual risks of surgery plus the known effects on urinary continence and potency. I don't know what I'd do if push came to shove, but the logical part of my brain is telling me - hold off on that surgery.

[pjoshea13 in reply to AlanMeyer]

Alan,

I wonder if a benefit of debulking has been established for other cancers?

...

One way of looking at this is that the statistics for PCa look good (ratio of deaths to new cases) because most cases do not become metastatic. The literature on metastatic disease, however, paints a grim picture. Faced with disease that has become very aggressive, a very aggressive response becomes more acceptable.

...

My own view is that we shouldn't discount the threat that the diseased prostate still poses, no matter how many mets we might have.

-Patrick

[AlanMeyer in reply to pjoshea13]

Perhaps the number and size of the mets is important here. For example, if you've got significant mets in a vital organ - brain, lung, liver, heart - performing a major surgery on the prostate really does seem to be besides the point.

Not having a well designed, randomized clinical trial here really hampers our ability to judge any of this. As the authors stated, the evidence really is subject to bias. Urologists can make a lot of money on surgeries just as radiation oncologists can make a lot of money on radiation procedures.

It is also possible, even without conscious intent to bias the results, for docs to steer people whom they think can be helped into getting the surgery and steer people whom they think are beyond help into avoiding it. In that case, the difference in outcomes can be due to the selections for each group rather than the treatment.

Alan

[Hidden in reply to AlanMeyer]

How about a 'surgery' that doesn't involve cutting but which is pretty close to the effectiveness of RP -- HIFU? Very little risk of incontinence or impotence when done by a capable practitioner.

[Hidden]

I regret not having it removed. I realize it was a mistake on my part for not knowing anything about the disease I had. But, it was a bang bang decision to do radiation and ADT. Now I have the same consequences the docs were harping on if I did have RP. The only difference is I got the thing still.

Joe