The Surgical Management Of Localized Prostate Cancer: Opportunities And Limitations
Dr. Scardino started by citing the Bill-Axelson trial that shows a decrease in metastatic rate, disease specific and overall survival in patients treated with RP vs. watchful waiting. He said RP provides excellent control of localized CAP. He thought overtreatment was an issue and RP should be reserved for CaP that poses meaningful threat. Among 6,490 patients having an RP at MSKCC since 1983 there is a freedom from PSA progression in 75%. The 15 year CaP specific survival rate is 93%. Even 40% of men with pT3 tumors are alive at 15 years and 45% with a PSA >20ng/ml are alive at 15 years.
He discussed the role of RP in high-risk CaP. In the literature up to 20% meet these criteria and 38% meet it using the criteria of PFAV>2ng/ml/yr. The 15 year freedom from progression in this group, however is above 45%. This suggests that perhaps avoiding RP in high risk patients is not appropriate.
The goals of RP are complete cancer removal, with minimal morbidity, early return to normal activities and no positive surgical margins or loss of continence or potency. However, nationwide the complications occur to a significant extent. Recovery of urinary continence was 96% and recovery of erections was 67%, and at 2 years only 60% are cancer free, continent and potent. He then evaluated to what degree outcomes are related to variables such as surgeon volume. While mortality did not differ among different surgical volumes, the incontintnece and impotency rates did. He showed a significant degree of heterogeneity regarding continence rates among surgeons at MSKCC. Positive surgical margins also differed among surgeons and this had significant implications for patients. Biochemical recurrence from 4 institutions (7,800 men) found that BCR was higher if a patient was operated on earlier in a surgeons' individual career. Also, a 5-year BCR of 18% was found for more inexperienced surgeons compared to 11% for experienced surgeons. Most disturbing said Dr. Scardino was that among those with high volume career total RP's, there was still variability. This points to differences in surgical technique. Fellowship trained and non-fellowship trained surgeons had similar outcomes at the onset of their careers, but fellowship trained urologists had improvement in outcomes to a greater extent than non-fellowship trained urologists. Research in surgical technique is an important area to continue to improve outcomes for patients.
Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS
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Chirurgicale de gestionare a cancerului de prostatã localizat: Oportunitãþi ºi limitãri - The Surgical Management Of Localized Prostate Cancer: Opportunities And Limitations - articole medicale engleza - startsanatate