Can a patient with metastatic prostate cancer undergo prostate removal?

Prostate Removal in Metastatic Prostate Cancer

No, radical prostatectomy is not standard treatment for patients with metastatic prostate cancer—the primary treatment is systemic androgen deprivation therapy (ADT), with or without additional agents like docetaxel or androgen receptor pathway inhibitors. 1, 2

Standard Treatment for Metastatic Disease

Immediate continuous castration (either surgical orchiectomy or medical castration with LHRH agonists) is the preferred treatment option for metastatic hormone-naïve prostate cancer. 1 The focus is on systemic control of disease, not local surgical intervention.

First-Line Systemic Therapy Options:

• Bilateral orchiectomy or LHRH agonists are the recommended initial treatments, with both providing equivalent survival outcomes 1
• ADT plus docetaxel chemotherapy is first-line treatment for patients fit enough to receive it, particularly those with high-volume metastatic disease 3, 2
• Androgen receptor pathway inhibitors (abiraterone, darolutamide) added to ADT improve median overall survival from 36.5 months to 53.3 months 4
• When starting LHRH agonists, an antiandrogen should be given for 3-4 weeks to prevent testosterone flare 1, 2

The Exception: Low-Volume Oligometastatic Disease

Radiation therapy to the prostate (not prostatectomy) may be considered in highly selected patients with low-volume metastatic disease. 5 The STAMPEDE trial demonstrated a survival advantage for radiotherapy in low-volume metastatic disease (hazard ratio 0.68; 95% CI 0.52-0.90) 5. However, this applies to radiation therapy, not surgical removal.

Why Surgery Is Not Performed:

• No survival benefit demonstrated: Radical prostatectomy has not been shown to improve mortality or morbidity in the metastatic setting when systemic therapy is the standard 1
• Systemic disease requires systemic treatment: Metastatic prostate cancer is a systemic disease where cancer has already spread beyond the prostate, making local removal of the primary tumor ineffective as sole therapy 2, 6
• Morbidity concerns: Surgery carries significant risks (incontinence, erectile dysfunction, blood loss) without proven benefit in the metastatic setting 7

Treatment Algorithm for Metastatic Prostate Cancer:

1. Confirm metastatic disease with bone scan and CT/MRI of abdomen and pelvis 2
2. Initiate ADT immediately (orchiectomy or LHRH agonist) 1
3. Add docetaxel if patient is fit and has high-volume disease 3, 2
4. Consider androgen receptor pathway inhibitor (abiraterone, enzalutamide, darolutamide) for improved survival 2, 4
5. Reserve radiation therapy to prostate only for low-volume oligometastatic disease in selected cases 5
6. Monitor with PSA and clinical assessment, managing ADT side effects 2

Critical Pitfalls to Avoid:

• Do not delay systemic therapy to pursue local surgical treatment—this worsens outcomes 1
• Do not confuse locally advanced (T3/T4) disease with metastatic disease: Radical prostatectomy may be considered in highly selected T3/T4 cases without metastases, but only after multidisciplinary discussion 1
• Recognize that PSA is not always reliable in undifferentiated or anaplastic metastatic prostate cancer with neuroendocrine features 1, 2