Is radical prostatectomy an appropriate treatment for stage A and B prostate cancer?

From the Guidelines

Radical prostatectomy is an appropriate treatment option for stage A and B prostate cancer, offering excellent cancer control with potential for cure, especially for patients with good overall health and a life expectancy of at least 10 years. This surgical procedure, which involves complete removal of the prostate gland and some surrounding tissues, is considered a standard curative treatment option for localized prostate cancer that has not spread beyond the prostate 1. The decision to undergo radical prostatectomy should be based on individual factors, including the patient's age, overall health, Gleason score, PSA level, and personal preferences regarding quality of life considerations and potential side effects.

Some key considerations for radical prostatectomy include:

• The procedure can be performed through traditional open surgery, laparoscopically, or with robotic assistance, with the latter approaches potentially offering faster recovery times and less blood loss 1.
• Patients should be aware of potential side effects, including urinary incontinence and erectile dysfunction, though nerve-sparing techniques can help minimize these risks 1.
• Recovery typically involves 1-2 days in hospital followed by 3-6 weeks of limited activity, with a catheter in place for 1-2 weeks post-surgery.
• The appropriateness of radical prostatectomy versus other treatments like radiation therapy or active surveillance depends on individual factors, including the patient's age, overall health, Gleason score, PSA level, and personal preferences regarding quality of life considerations and potential side effects 1.

It's also important to note that high-volume surgeons in high-volume centers generally provide better outcomes, and that laparoscopic and robot-assisted radical prostatectomy are used commonly, with results comparable to those of open surgical approaches 1. Additionally, salvage radical prostatectomy is an option for highly selected patients with local recurrence after external beam radiation therapy, brachytherapy, or cryotherapy in the absence of metastases, but the morbidity is high 1.

In terms of specific guidelines, the European Society for Medical Oncology (ESMO) recommends that patients with low-risk disease (T1–2a, Gleason <6, PSA <10 mg/l) be informed of the potential benefits and harms of the different options, including radical prostatectomy, external beam radiotherapy, brachytherapy, and active surveillance 1. The National Comprehensive Cancer Network (NCCN) also recommends radical prostatectomy as an appropriate therapy for any patient with clinically localized prostate cancer that can be completely excised surgically, who has a life expectancy of 10 years, and has no serious comorbid conditions that would contraindicate an elective operation 1.

From the Research

Radical Prostatectomy for Stage A and B Prostate Cancer

• Radical prostatectomy is a treatment option for prostate cancer, and its appropriateness depends on the stage and risk of the disease 2.
• For patients with intermediate-risk and high-risk disease (Gleason score 7-9 or Grade Groups 2-5), radical prostatectomy is considered an appropriate treatment option as it can prevent further metastatic seeding of potentially lethal clones of prostate cancer cells 2.
• The use of radical prostatectomy has evolved over time, with the minimally invasive robot-assisted method becoming more popular, and its indications have changed with the introduction of new molecular insights and active surveillance programs 2.
• Studies have shown that radical prostatectomy can improve survival in selected metastatic prostate cancer patients, with lower cancer-specific mortality rates compared to external beam radiation therapy 3.
• However, the decision to undergo radical prostatectomy should be made on a case-by-case basis, taking into account the individual patient's characteristics, disease stage, and risk factors 4, 5, 6.

Patient Selection and Outcomes

• Patient selection is crucial in determining the outcomes of radical prostatectomy, with factors such as Gleason score, pathological stage, and preoperative prostate-specific antigen levels influencing the decision-making process 4, 5, 6.
• Studies have reported varying outcomes for patients undergoing radical prostatectomy, with some showing significant improvements in disease-free survival and overall survival, while others have reported higher rates of biochemical recurrence and clinical recurrence 4, 5, 6.
• The introduction of new Gleason grade grouping systems has helped to refine patient selection and predict outcomes, with patients having Gleason score 9-10 showing worse biochemical and clinical recurrence-free survival compared to those with Gleason score 8 4.

Comparison with Other Treatment Options

• Radical prostatectomy has been compared to other treatment options, such as external beam radiation therapy, with some studies showing improved outcomes with radical prostatectomy in selected patients 5, 3.
• However, other studies have reported similar outcomes between radical prostatectomy and external beam radiation therapy, highlighting the need for individualized treatment decisions 5, 6.
• The role of radical prostatectomy in the management of metastatic prostate cancer is still evolving, with ongoing clinical trials aiming to provide further validation of its use in this setting 3.