Management Of The Primary Tumor In High Risk Nonmetastatic Prostate Cancer - Argument For An Integrated Approach Starting With Surgery

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Clinical Trials / Drug Trials
Article Date: 02 Jun 2008 - 4:00 PDT

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ORLANDO, FL (UroToday.com) - Dr. Mitchell Benson argued that surgery offers unsurpassed local control if respectable. He compared it to lumpectomy in breast cancer. The concordance of high risk patients by nomograms with surgery was over 90%. In African-Americans, there was a 2.3 fold more likely to have a greater that 15% change in their risk of progression. Thus, identification of high risk patients is critical. The recurrence of disease in the patients does not necessarily equate with death from disease in the Columbia database.

The correlation of PSA recurrence and clinical disease progression are not well defined. Molecular markers come into play for identifying these patients. The right operation is the removal of the entire prostate and an extended lymph node dissection. He reviewed the Messing trial, which did not have PSA as entry criteria. However, PSA was available in most. Many of the patients had positive margins in addition to seminal vesicle invasion and positive lymph nodes. Immediate androgen deprivation therapy resulted in 75% survival in these patients at 10 years. He adjusted the patient population using the Kattan nomograms and this resulted in an even further survival benefit. About 20% of the patients without ADT survived, suggesting the benefit of PLND. The benefit of extended PLND is being defined, but there is suggestion from Dr. Studor's group that a therapeutic benefit may exist.

Adjuvant docetaxel following surgery was of benefit, but toxicity was significant. Current Phase III trials include the VA trial randomized to adjuvant docetaxel or observation, but not ADT. The CALBG90203 randomizes high risk men to surgery or neoadjuvant docetaxel followed by RP. He concluded that use of surgery avoids the obligatory use of ADT in some patients.

Presented by Mitchell Benson, MD, at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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