Prostate surgery – the best option for patients with high-grade prostate cancer and low PSA level

Men who have been diagnosed with high-risk prostate cancer but who have a relatively low PSA level of 10ng/mL or even less may have more benefits from prostatectomy, than from radiation.

Usually, high-grade prostate cancer is treated by means of radiation, brachytherapy, hormone therapy, HIFU and, less common, by means of prostate surgery. However, when a man’s PSA level is not high, being a maximum of 10 ng/mL, prostatectomy proved to bring about the best outcomes. 

What did the study reveal about the effectiveness of radical prostate surgery?

Researchers conducted a study on this theme, surveying 9114 men with Gleason Score 8-10 and PSA Levels of 10ng/mL or less. Currently, there is no standard treatment for these patients. 

From the 9114 men included in the survey, 4175 underwent radical prostatectomy, 4114 were treated with external beam radiation and 825 received a combined treatment (external beam radiation along with brachytherapy). These prostate cancer patients were surveyed on a follow-up period of almost 4 years. 

All 3 types of treatment were assessed in terms of the risk of mortality they carried.

It was concluded that patients who underwent radical prostatectomy had a decrease in the risk of death, compared to those who received radiation alone or EBRT+BT(External beam radiation therapy + Brachytherapy). External beam radiation therapy proved to have a 2.5 increased risk of prostate cancer mortality than a radical prostatectomy.

Moreover, the study revealed that the combination of external beam radiation therapy with brachytherapy may be an option for patients with high-grade prostate cancer (aged 70+) and a low PSA level (2ng/mL). For these patients, the radical prostatectomy and EBRT+BT proved to provide similar outcomes. 

The overall survival rates for a period of 3 years was 98,4% for radical prostatectomy, 95,1% for external beam radiation therapy (EBRT) and 96.7% for EBRT+BT. The 5-year overall survival rates were a little bit lower, radical prostatectomy still being the most effective treatment. The 10-year overall survival rates show that radical prostatectomy is about 10% more beneficial for high-grade prostate cancer patients than radiation (67.5% vs. 58%). 

The Prostate Cancer-Specific Mortality is another indicator of how effective is a prostate cancer treatment.

For the 3-year period, the PCSM was 0.5 for the group of men who underwent radical prostatectomy, 1.4 % for those who received EBRT and 0.8% for the combined treatment of EBRT and BT. For the 5-year period, the PCSM rates were considerably higher, especially for the EBRT group – 4,8% compared to 1.4% for the radical prostatectomy group (RP). The 10-year PCSM rates also showed that RP ensures the lowest chance of prostate cancer mortality. 

However, each study has its own limitations. First, the population database was based on the SEER registry (Surveillance, Epidemiology and End Results), which is limited in providing information about the aggressiveness of the prostate cancer in each patient.

What is more, a comparative study on the effectiveness of each treatment can be accurate only when it contains all data needed about each treatment. In this case, researchers lacked information about the duration of the androgen deprivation therapy given with radiation and the dosage or administration details on the radiation used, which is an important factor in understanding how was the treatment applied.

A comparison between 2 types of radiation would have been easier to do, but comparing 3 different types of treatment is a challenge. When a study compares radiation to surgery, it is very important to be taken into account that patients are different, being eligible or not for a certain treatment, depending on how sick they are. These important details would help have a better and more accurate understanding of the study’s findings.

Why is prostate surgery the first line of treatment? 

However, the study provides valuable insights into the effectiveness of radical prostatectomy over radiation or other treatments. An important reason why radical prostatectomy is considered the first line of treatment even for high-grade patients (but with low PSA levels) is that, in case of cancer recurrence, radiation therapy can be applied, allowing patients to have a second treatment option. This is not the case with those who receive radiation first. Very few urologists are willing to perform surgery after radiation and the vast majority only recommend ADT(Androgen Deprivation Therapy), so men do not have many options in case of cancer recurrence.

A radical prostatectomy can be performed in 3 different ways:

• Open radical prostatectomy – This is the traditional way that involves cutting the abdomen and a long recovery period.
• Laparoscopic prostatectomy (Keyhole prostatectomy) – the surgeon makes several small incisions and uses long surgical instruments to remove the prostate. A small camera is also inserted into the incision to increase visibility.
• Robotic prostatectomy – using the da Vinci Surgical System, 4-5 small incisions are made in a man’s abdomen. The surgeon controls the movements of the robot through his console. The 3 D visual system and 10-15X magnification of the surgical area ensure precise cuts with minimal blood loss and nerve damage. 

What are the benefits of robotic prostatectomy?

Total cancer removal

Minimal blood loss – No need for blood transfusions

Quick recovery

Short hospitalization

Sexual Potency

Urinary Continence

Prostate cancer has many treatment options, depending on the grade of cancer and its aggressiveness. Studies like the one presented in this article can help urologists and prostate cancer patients decide upon the best treatment for cancer, the treatment with the highest proven overall survival rates and the least PCSM rates.