Few well performed studies address management of lymph node positive prostate cancer

Dr. Gregory Swanson and associates from the University of Texas, San Antonio Health Science Center reviews the data for various treatment options in patients with lymph node positive prostate cancer (CaP). Their paper appears in the epub version of Cancer.

A role for surgery as monotherapy in patients with lymph node positive CaP remains unclear, with 10-year disease free survival rates from 7-17%. Often, surgeons finding positive lymph nodes abort the prostatectomy, but some institutions proceed with local control. In the largest study reported at a median follow-up of 4.1 years, 76% of patients had clinically detected treatment failure by 10 years. The argument that local control prevents symptomatic problems later was tested in one study and the rate of complications in the surgery patients was no worse with radiotherapy or androgen deprivation (AD).

The addition of AD to RP is now an accepted standard, primary based upon the report by Messing that the addition of AD resulted in overall survival rate improvement from 49% to 72% and cause-specific survival rates from 57% to 87%. Series from the Mayo Clinic suggest the addition of AD to RP improves the local failure rate, rate of distant metastasis, and cancer death rate, but not overall survival.

AD therapy alone is likely inferior to RP plus AD in studies that have addressed it. However, an EORTC trial did not demonstrate that immediate AD was superior to delayed AD in patients with lymph node positive CaP.

The addition of radiotherapy (XRT) to RP results in 10-year disease-free survival rates around 37% for those with a single microscopic lymph node involved, 25% with a single positive node, and 10% for those with >1 positive lymph node. XRT alone has a survival rate of 30%, with 10-year disease free survival less than 20%. The combination of XRT and AD is commonly employed for lymph node positive CaP patients. The 10-year survival rate is 67% and disease free survival is 80% with combined treatment. This is similar to RP plus AD combination therapy.

Chemotherapy trials are few, but estramustine had some reported benefit in these lymph node positive CaP patients. Trials using docetaxel are underway. From Dr. Swanson's paper, it is apparent that good randomized prospective trials are few and leave the best treatment for lymph node positive CaP unanswered. Combination therapy with AD plus either RP or XRT seem to be reasonable options based upon available data.

By Christopher P. Evans, MD