Radical prostatectomy & metastatic PCa.

[pjoshea13]

New study below [1].

"Newly diagnosed metastatic prostate cancer patients with M1a/b substages, treated with radical prostatectomy or external beam radiation therapy were abstracted from the Surveillance, Epidemiology and End Results database (2004-2016)."

"Of 4280 patients, 954 (22.3%) were treated with radical prostatectomy. After propensity score matching, 5-year cancer-specific mortality was 47.0 versus 53.0% in radical prostatectomy versus external beam radiation therapy patients"

"Conclusion: In metastatic prostate cancer, radical prostatectomy results in lower cancer-specific mortality relative to external beam radiation therapy. Even after adjustment for age at diagnosis, prostate-specific antigen and biopsy Gleason grade grouping, lower cancer-specific mortality rates are recorded in radical prostatectomy patients than in external beam radiation therapy patients. As a result, radical prostatectomy should be considered as a treatment option in selected metastatic prostate cancer patients."

-Patrick

[1] pubmed.ncbi.nlm.nih.gov/340...

Int J Urol

. 2021 May 28. doi: 10.1111/iju.14586. Online ahead of print.

Radical prostatectomy improves survival in selected metastatic prostate cancer patients: A North American population-based study

Lara Franziska Stolzenbach 1 2 , Marina Deuker 2 3 , Claudia Collà-Ruvolo 2 4 , Luigi Nocera 2 5 , Zhe Tian 2 , Tobias Maurer 1 6 , Thomas Steuber 1 , Derya Tilki 1 6 , Alberto Briganti 5 , Fred Saad 2 , Felix Kh Chun 3 , Markus Graefen 1 , Pierre I Karakiewicz 2

Affiliations collapse

Affiliations

1 Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

2 Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

3 Department of Urology, University Hospital Frankfurt, Frankfurt, Germany.

4 Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy.

5 Department of Urology and Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy.

6 Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

PMID: 34047401 DOI: 10.1111/iju.14586

Abstract

Objective: To test whether radical prostatectomy might result in better survival than external beam radiation therapy in metastatic prostate cancer patients.

Methods: Newly diagnosed metastatic prostate cancer patients with M1a/b substages, treated with radical prostatectomy or external beam radiation therapy were abstracted from the Surveillance, Epidemiology and End Results database (2004-2016). Temporal trend analyses, propensity score matching, cumulative incidence plots, multivariate competing risks regression models and landmark analyses were used.

Results: Of 4280 patients, 954 (22.3%) were treated with radical prostatectomy. After propensity score matching, 5-year cancer-specific mortality was 47.0 versus 53.0% in radical prostatectomy versus external beam radiation therapy patients (P = 0.003). In propensity score matched competing risks regression models, radical prostatectomy was associated with lower cancer-specific mortality versus external beam radiation therapy (hazard ratio 0.79, 95% confidence interval 0.79-0.90; P = 0.001). Finally, landmark analyses rejected the bias favoring radical prostatectomy. Finally, in subgroup analyses, we relied on selection criteria that most closely resembled the STAMPEDE criteria and a similar hazard ratio of 0.8 (P < 0.001) was recorded.

Conclusion: In metastatic prostate cancer, radical prostatectomy results in lower cancer-specific mortality relative to external beam radiation therapy. Even after adjustment for age at diagnosis, prostate-specific antigen and biopsy Gleason grade grouping, lower cancer-specific mortality rates are recorded in radical prostatectomy patients than in external beam radiation therapy patients. As a result, radical prostatectomy should be considered as a treatment option in selected metastatic prostate cancer patients. However, further validation will be provided by ongoing clinical trials.

Keywords: North American population; external beam radiation therapy; metastatic prostate cancer; radical prostatectomy.

© 2021 The Authors. International Journal of Urology published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Urological Association.

References

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[cesanon]

"Conclusion: In metastatic prostate cancer, radical prostatectomy results in lower cancer-specific mortality relative to external beam radiation therapy. Even after adjustment for age at diagnosis, prostate-specific antigen and biopsy Gleason grade grouping, lower cancer-specific mortality rates are recorded in radical prostatectomy patients than in external beam radiation therapy patients. As a result, radical prostatectomy should be considered as a treatment option in selected metastatic prostate cancer patients."

Very very very interesting.

I always wondered about that.

Is this a lone study on the matter or are there other concurring studies?

[MateoBeach]

Looking at all the reference articles, it shows there is value in eliminating the “mother ship” (prostate gland) which is consistent with how it probably provides supportive molecular resources for the metastatic sites. This article clearly favors RP. But I must wonder if more frail patients at higher risk might have been steered away from surgery towards RT and biased the results.

[6357axbz in reply to MateoBeach]

Good point

[pjoshea13 in reply to MateoBeach]

Speaking of bias - only 22.3% had RP.

Years ago, RP was not considered to be an option for mPCa. How often is it presented as an option today?

The day I had my RP, another patient "with lesser cancer" was stapled back up because of cancer in a lymph node. My RP was not successful, but I had gotten away with it. I always considered debulking to be desirable, but my opinion didn't matter back then.

And yet, considering the 5-year failure rate for RP, a lot of us were being debulked anyway,

-Patrick

[mikell in reply to pjoshea13]

What about Cyberknife treatment of the prostate? Was it ever an option? From everything I have studied, it appears to be a truly viable option that is very rarely used.

[TeleGuy in reply to pjoshea13]

That just seems to me to be so wrong, closing someone back up because of a positive LN and denying the benefit of debulking. I had two positive LN found during my surgery but still got the prostate out and, like @jfoesq below I'm happy with the results of debulking.

And I would argue that your RP *was* successful because you got rid of the mother ship.

[Hidden]

While this study does not apply to me because I am pT3N1M0 after my RP in June 2019, I have no regrets having the RP even though my post RP psa was not undetectable. It just seems logical that removing the primary tumor will result in longer survival. The evidence for this is not rock solid but for some men this treatment approach seems perfectly logical and yields positive results. I followed my RP with ADT and IMRT and have a PSA < 0.01 for well over 14 months. Preparing to start a ADT vacation after my last Eligard injection in July. Hoping for a durable remission.

[Tall_Allen]

Another inappropriate SEER database study.

[Dett in reply to Tall_Allen]

Could you elaborate?

[Tall_Allen in reply to Dett]

Database studies are really poor for this sort of thing (e.g. comparing therapies) because of (1) selection bias (the patients chosen to get one therapy vs another are chosen because they are good candidates for that therapy), and (2) unmeasured confounders (variables that affect results are not measured), and (3) lack of overlap (if, for example, most surgery patients are below 70, while most radiation patients are above 70, and there aren't enough overlapping patients to create a normal distribution), and (4) Simpson's paradox - aggregate data masks or reverses more finite comparisons. Studies like this should never be used to make decisions.

[George71]

As Patrick said -- just 5 years ago they wouldn't do surgery if any evidence of spread beyond the prostate -- now they will do surgery and radiation even if oglo-mets -- with curative intent.

Multi center trial based on real world evidence of benefit -- radiation (plus or minus ADT) plus surgery / or, surgery after radiation (plus or minus ADT) even for proven met spread outside prostate. Also radiation of mets post surgery or surgery post radiation and rising PSA.

consultqd.clevelandclinic.o...

[Spyder54 in reply to George71]

Great article from Cleveland Clinic!

[6357axbz in reply to Spyder54]

I wonder why they don’t include debulking via RT...

[pjoshea13]

I just did the following searches on PubMed:

<cancer debulking> - 6,025 hits, beginning 1976

<cancer debulking prostate> - 59 hits - 53 of which are in past 20 years.

Why is PCa lagging behind? Perhaps because PCa oncologists love radiation (or hate urologists.)

-Patrick

[jfoesq]

I only provide the following info for info purposes. I make no recommendations.It's nice to see that the chance I took in following my oncologist's recommendation and having the surgery almost 9 years ago, which was NOT the SOC, APPEARS as though it MAY have been a smart choice. My oncologist back then was Dr. Howard Scher and I was only his 13th patient to have the surgery. I was aware it was not the SOC but I was only 54 and otherwise healthy and Dr. Scher thought it was worth the risk, so I took it. I am now more glad than ever that I did. I have GREAT respect for Tall-Allen and his criticism of the study may be correct. But- I came through the surgery well and this study provides me SOME comfort that I made a good decision in following Dr. Scher's advice.

[Spyder54 in reply to jfoesq]

Read your Bio, and know of SKM procedures.

Harvard Med on SKM

[Spyder54 in reply to Spyder54]

O’Shaugnessy of SKM

O’Shaugnessy of SKM

[pjoshea13 in reply to Spyder54]

full text paper:

ncbi.nlm.nih.gov/pmc/articl...

They call it "cytoreductive prostatectomy" these days.

-Patrick

[Spyder54]

I too respect Tall Allen immensely. I know that he is not easily swayed. I am 7 months since diagnosis GL 8. Oligometastic. MD Anderson is in Phase III of Swog 1802 with 1200 Stage 4 US Men because they know RRP after 7 months of ADT to put PCa in sennescence, followed by SABR/SBRT, is effective and has been curative, but they need to prove it scientifically. For 600 men in B group they do give ou a choice of RRP or RT. Mayo in Minnesota, Sloan Kettering in NY, Cleveland Clinic, and MD Anderson are all on this mission. I was turned away by MD Anderson because my PSA needed to be more stable. I posted a 5.4 at 7 months but then a 4.2 since and last week a 2.2. Just too late for their strict 28week protocol but I know I am right and will pursue removal of the Mother Ship at 8 months after diagnosis. Yes there is risk. It is an educated risk however, with the ability to choose a Surgeon with over 1500 RRP’s, a trusted Radiologist with a good track record. At 67, and in good health, I feel I have the potential for a good outcome.

Thanks Patrick,

Mike K

St Pete

[Bethpage in reply to Spyder54]

Spyder54, I'm seeing this late, but wanted to tell you...my husband had a simple prostatectomy in 2014 (11 years of negative biopsies, so we didn't know he had cancer). Because of a rising PSA and the belief that he had "gotten it all," Vipul Patel in Celebration talked my husband into and performed a salvage surgery in 2017. Husband was 71 at first surgery, 74 at second. He was in excellent health and didn't have complication one from either surgery, was back in the classroom teaching math (sitting) to 6th graders on day 5 after each of the two surgeries. Best wishes to you!

[Spyder54 in reply to Bethpage]

I see this was 11 mos ago. I know 2 men here in St Pete who went to Vip Patel in Orlando. Think he is up to 15,000 RRP’s now. They talk about 2 advil the first night, and 2 advil the 2nd night with 5 day catheter being the hardest part of the surgery. Both had good results. I do think he prefers the easy ones. He told me NO in no uncertain terms. Referred me to his Oncologist and Radiologist, who told me No on Radiation therapy and to keep it for later on when I get bone pain. McBride at MSKCC did 5 days of SBRT To Primary Prostate, and 3 days to T5 in spine, in Jan 2022. Just had my first PSA 3-1/2 mos since SBRT, and 5 mos since last PSA in early December. I was at my low nadir on Dec 2, 2021 of .260. This week .095. Yeahhhh! McBride said this is confirmation that SBRT is working and should extend life. The Stampede Trial (Arm L, I think?) confirmed this approach is good with very strong 3 year number on overall survival. I wish your husband many years of good health, and teaching of 6th graders.

Best,

Mike

[Bethpage in reply to Spyder54]

You're a good judge of the specialist. He does prefer the easy ones. He didn't achieve that with my husband as he had to deal with him (me) for 5 years after swearing that my husband would be "the first man cured of prostate cancer by salvage prostatectomy." Nope, his 8 inches of record-keeping right down the drain. And he no-showed our exit appointment. Went out the back door. Guessing the MO is still Alemany and the RO is still Biagioli? IMO, you hit the jackpot with McBride. Congrats!

[jfoesq]

Best of luck to you and thx for the info from Harvard Med.