Table 9. Treatment Options by Stage for Prostate Cancer continued...
(Refer to the Stage II Prostate Cancer Treatment section of this summary for more information.)
A radical prostatectomy is usually reserved for patients who:[17,18,19]
- Are in good health and elect surgical intervention.
- Have tumor confined to the prostate gland (stage I and stage II).
Prostatectomy can be performed by the perineal or retropubic approach. The perineal approach requires a separate incision for lymph node dissection. Laparoscopic lymphadenectomy is technically possible and accomplished with much less patient morbidity. For small, well-differentiated nodules, the incidence of positive pelvic nodes is less than 20%, and pelvic node dissection may be omitted. With larger, less-differentiated tumors, a pelvic lymph node dissection is more important. The value of pelvic node dissection (i.e., open surgical or laparoscopic) in these cases is not therapeutic but spares patients with positive nodes the morbidity of prostatectomy. Radical prostatectomy is not usually performed if frozen section evaluation of pelvic nodes reveals metastases; such patients should be considered for entry into existing clinical trials or receive radiation therapy to control local symptoms.
The role of preoperative (neoadjuvant) hormonal therapy is not established.[22,23]
Following radical prostatectomy, pathologic evaluation stratifies tumor extent into the following classes:
- Margin-positive disease—The incidence of disease recurrence increases when the tumor margins are positive.[7,10,24] Results of the outcome of patients with positive surgical margins have not been systematically reported.
- Specimen-confined disease—The incidence of disease recurrence increases when the tumor is not specimen-confined (extracapsular).[7,10]
- Organ-confined disease—Patients with extraprostatic disease (not organ-confined) are suitable candidates for clinical trials such as the Radiation Therapy Oncology Group's (RTOG [RTOG-9601]) trial, for example. These trials include evaluation of postoperative radiation delivery, cytotoxic agents, and hormonal treatment using luteinizing hormone-releasing hormone (LH-RH) agonists and/or antiandrogens.
Radical prostatectomy compared with other treatment options
In 1993, a structured literature review of 144 papers was done in an attempt to compare the three primary treatment strategies for clinically localized prostate cancer:
- Radical prostatectomy.
- Definitive radiation therapy.
- Observation (watchful waiting or active surveillance).
The authors concluded that poor reporting and selection factors within all series precluded a valid comparison of efficacy for the three management strategies.
In a literature review of case series of patients with palpable, clinically localized disease, the authors found that 10-year prostate cancer-specific survival rates were best in radical prostatectomy series (about 93%), worst in radiation therapy series (about 75%), and intermediate with deferred treatment (about 85%). Because it is highly unlikely that radiation therapy would worsen disease-specific survival, the most likely explanation is that selection factors affect choice of treatment. Such selection factors make comparisons of therapeutic strategies imprecise.
Radical prostatectomy has been compared with watchful waiting or active surveillance in men with early-stage disease (i.e., clinical stages T1b, T1c, or T2) in randomized trials, with conflicting results. The difference in results may be the result of differences in how the men were diagnosed with prostate cancer.