Even in the presence of screening, there is benefit to radical prostatectomy (RP) in prostate cancer patients, however, the benefit is limited to a subgroup of patients and can take years to become evident according to a study published February 14 in the Journal of the National Cancer Institute.
The Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) trial identified that RP lowered prostate cancer deaths with a statistically significant absolute mortality difference (AMD) between RP and watchful waiting (WW) of 6.1%. The Prostate Cancer Intervention Versus Observation Trail (PIVOT) recently published results from a US-based trial comparing the effectiveness of RP compared with watchful waiting (WW). The PIVOT trial found a non-statistically significant reduction in the risk of prostate cancer death in the RP group with an absolute risk reduction of 3% after a 12-year follow-up. Although these findings may seem inconsistent with the results from the Scandinavian trial, it is unknown if more frequent screen detection in PIVOT can explain the lower AMD.
In order to determine if a more frequent screen detection in PIVOT explains the lower AMD when compared to the SPCG-4 trial, Jing Xia, Ph.D., of the Fred Hutchinson Cancer Research Center in Seattle and colleagues, assumed that the SPCG-4 trial represented RP efficacy and prostate cancer survival in an unscreened population. They then adjusted prostate cancer survival using published estimates of overdiagnosis and lead time to evaluate the effect of screen detection on disease-specific deaths and the observed AMD.
The researchers found that overdiagnosis and lead time explains the lower AMD in PIVOT if the RP efficacy and prostate cancer survival in the absence of screening are comparable to that of the SPCG-4 trial. They conclude that if these findings are the correct explanation, then a specific set of cases should not be treated with RP and that their identification should lead to a better understanding of the RP benefit in the remaining cases. “PIVOT should not be interpreted as evidence that RP is not efficacious in reducing prostate cancer mortality,” the researchers write. “PIVOT should encourage us to develop tests to identify cases for which immediate treatment is beneficial.”
What a radical prostatectomy is
A radical prostatectomy is a common operation for treating prostate cancer. It used to be called total prostatectomy. This means using surgery to remove all of the prostate gland through a cut in your abdomen or the area between the testicles and the back passage (perineum). The aim of this type of surgery is to cure the cancer. Your surgeon may suggest radical prostatectomy if
Your cancer has not spread outside your prostate
You are younger, rather than older, and have a high grade tumour
Who has radical prostatectomy?
Radical prostatectomy is done more often in younger men because they are more likely to
Be fit enough for such major surgery
Have a faster growing tumour that needs radical treatment
Die from their cancer rather than other health conditions if it is not successfully treated
Radical prostatectomy is major surgery with many possible side effects. If you are an older man with a slowly growing prostate cancer, this type of surgery may not be necessary for you. This is because your cancer may be so slow growing that you are more likely to die of old age or other causes than from the prostate cancer. In many cases, it isn’t worth putting you through the side effects if the treatment will not lengthen your life span.
There are four main types of radical prostatectomy surgery. These procedures take about 3 to 4 hours:
Radical retropubic prostatectomy: Your surgeon will make a cut starting just below your belly button and reaching to your pubic bone. The entire surgery should take 90 minutes to 4 hours.
Laparoscopic radical prostatectomy: The surgeon makes several small cuts instead of one big cut. Long, thin tools are placed inside the cuts. The surgeon puts a thin tube with a video camera (laparoscope) inside one of the cuts. This helps the surgeon see inside your belly during the procedure.
Robotic-assisted laparoscopic prostatectomy: Sometimes laparoscopic surgery is done using a robotic system. The surgeon moves the robotic arm while sitting at a computer monitor near the operating table. Not every hospital can do robotic surgery.
Radical perineal prostatectomy: Your surgeon makes a cut in the skin between your anus and base of the scrotum (the perineum). The cut is smaller than with the retropubic technique. This makes it harder for the surgeon to spare the nerves around the prostate, or to remove nearby lymph nodes. Perineal surgery usually takes less time than the retropubic way. There is also less blood loss.
Journal of the National Cancer Institute