Surgery for localised, locally advanced and high risk prostate cancer

Steven Joniau, MD, PhD

University Hospitals Leuven

Leuven

Belgium

Surgery for localized, locally advanced and

high risk prostate cancer

117,328 patients with prostate cancer

26,410 low risk (22.5%)

cT1-T2, PSA <10 ng/ml AND Gleason 2-6

26,611 intermediate risk (22.7%)

cT1-T2 AND PSA 10 - <20 OR Gleason 7

30,159 high risk (25.7%)

cT3 or PSA 20-50 or Gleason 8-10

Non-curatively treated

Rider JR et al. Eur Urol 2012 2

Who dies of PCa? Natural evolution of non-curatively treated PCa

10%

20%

35-40%

Rider JR et al. Eur Urol 2012

All ages <65 years 65-75 years >75 years

Prostate cancer Cardiovascular Other

Lo

w r

isk

M

ed

ium

ris

k

Hig

h r

isk

Who dies of PCa?

Natural evolution of non-curatively treated PCa

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Complete removal of the prostate, seminal vesicles, and pelvic lymph nodes (when necessary)

• With minimal perioperative morbidity, no blood transfusions, and early return to normal activities

• No positive surgical margins

• No long-term loss of continence or potency

Goals of modern radical prostatectomy (RP)

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PIVOT Trial

PSA detected

RP vs observation for localised PCa

RP did not significantly reduce all-cause or PCa-specific mortality as compared

with observation

Wilt TJ et al. N Engl J Med 2012;367:203-13

PCa-specific mortality

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Low-risk PCa

PCa specific mortality

6

Overall mortality

Wilt TJ et al. N Engl J Med 2012;367:203-13

PCa specific mortality

7

Overall mortality

Intermediate risk PCa

Wilt TJ et al. N Engl J Med 2012;367:203-13

PCa-specific survival

~45%

~17%

P= 0.05

High risk PCa

8 Wilt TJ et al. N Engl J Med 2012;367:203-13

Briganti A, Spahn M, Joniau S et al. for EMPaCT Eur Urol 2013

Only men ≤ 59 years old had higher risk of PCa-related

death than death-related to other causes

10%

<10%

Prostate cancer Other

MORTALITY RATES FOR SURGICALLY TREATED

HIGH-RISK PCa

Cooperberg M, et al. AUA 2015 – Data from CAPSURE

Which treatment for which cancer?

Up untill 2007, Low-risk PCa was too often actively treated,

while high-risk PCa was too often undertreated 10

Cooperberg M, et al. AUA 2015 – Data from CAPSURE 11

After 2007, Low-risk PCa was more often treated with AS/WW,

while high-risk PCa was more often actively treated!!!

Which treatment for which cancer?

Cumulative incidence function estimates of cancer

specific and other cause mortality survival curves

(n=34 515), stratified according to treatment type.

Sooriakumaran P et al. BMJ 2014;348:bmj.g1502

M+ or N+ or T4 or

PSA>50 Low Intermediate High

RP

RT

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Sooriakumaran P et al. BMJ 2014;348:bmj.g1502

13

Cumulative incidence function estimates of cancer

specific and other cause mortality survival curves

(n=34 515), stratified according to treatment type.

Cooperberg M, et al. AUA 2015 – Data from CAPSURE 14

HIGH-RISK 15-Y

EA

R C

AN

CE

R M

OR

TA

LIT

Y

- Retrospective analysis of data from the Norwegian Prostate Cancer Registry, 2004-2005

- 3486 patients, RP (n = 895), EBRT +/- ADT (n = 1339), or no local treatment (n = 1252)

- Clinical stage T1-T3, PSA ≤100 ng/ml, D’Amico risk group stratification

- Comparison of active local treatment (RP, RAD) versus no active local treatment (NoLocTrt)

PCa mortality

Other cause mortality

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HIGH-RISK

Big surgeon, big incision…?

• NO difference in positive surgical margins

• NO difference in incontinence

• SMALL difference in erectile dysfunction in favor of RALP

The changing role of surgery

• Properly performed, RP is a highly effective treatment

for high-risk prostate cancer in men with a sufficiently long life expectancy to justify the risks

• Outcomes of RP – cancer control, peri-op complications, and long-term urinary and sexual function – are directly related to the skill and experience of the surgeon, but not to the technology used (open v. robot-assisted)

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