Let’s begin with the assurance that doctors deeply want to cure their prostate cancer patients. Whether we are urologists, radiologists or oncologists, this is our most important goal. To fulfill that goal, we offer the treatments for which we are best trained. Urologists are surgeons, so in their specialty cutting out the entire prostate (with some surrounding tissue such as the seminal vesicles and nearby lymph nodes) offers the best chance of removing the cancer. The surgery, radical prostatectomy (RP), is a major operation. “Radical” means whole or all. It’s analogous to radical mastectomy for breast cancer: the whole breast, underlying muscle and nearby lymph nodes are taken in the effort to get out the cancer.
The success of radical surgery depends on containment. The American Cancer Society carefully hints that with RP, curative intention does not guarantee success: “Surgery is a common choice to try to cure prostate cancer if it is not thought to have spread outside the prostate gland.”[i] And WebMD points out that RP “can cure prostate cancer in men whose cancer is limited to the prostate.” I have underlined the most important words in these statements to illustrate that curing prostate cancer by RP may or may not be curative. Why? Because the urologist can’t be 100% certain that the cancer is still localized.
When a urologist recommends RP and says, “We’ll get it all out and you won’t have to worry about it,” it is said in good faith. The patient hears, “I can cure you” as a promise. However, RP comes with what I call an “uh-oh clause.” When the gland is removed – while the patient is still on the table – it is sent for examination by a specialist called a pathologist who examines the removed tissue under a microscope. In cases where the tumor has broken through the edge of the prostate capsule (extracapsular extension or ECE), the pathologist immediately notifies the surgeon that there were positive surgical margins. The Johns Hopkins Prostate Cancer Update explains:
In an ideal world, after radical prostatectomy, the pathologist would send a triumphant report to the surgeon: “I’ve looked at the prostate tissue you removed from Mr. Jones, and all of the edges are clear. Congratulations! You’ve removed all the cancer!”
Most often, it happens that way. Sometimes, however, the pathologist’s report is more ambiguous: Either the margins — the edges of the removed tumor — are “positive,” meaning they show cancer cells, or they’re “close,” meaning cancer is just a hair’s breadth away from the edge of the specimen.[ii]
If the margins are positive, there’s that sinking “uh-oh” feeling. The surgeon may have left cancer behind. A 2016 multicenter study of 4031 cases found that 34.3% had positive surgical margins.[iii] For that particular cohort of patients, RP failed to “cure” one-third of them. Furthermore, statistics show that if the tumor is > Gleason grade 4+3, the probability of ECE increases, yet most Gleason 4+3 patients are still recommended for “curative” RP.
Biochemical recurrence after RP
All prostate cancer patients who go through treatment – whether RP, radiation, or focal therapy – must have periodic PSA blood tests for the rest of their lives to monitor for what is called biochemical recurrence (BCR) or biochemical failure (BCF). In fact, when the final pathology shows a more aggressive tumor than the original biopsy, that patient is already at risk for BCR. For example, in one study of 3,671 patients who had BCR after robotic RP, 44.4% had a presurgery biopsy Gleason score ? 7, but after surgery 64.5% had Gleason score ? 7.[iv] In other words, during surgery 20% more patients were found to have higher risk disease. According to the standard BCR definition, a follow-up PSA greater than 0.2 ng/mL indicates BCR, meaning prostate cancer is growing somewhere. The sobering truth is that, even with clear surgical margins, BCR can occur even 10 or more years after surgery due to several causes, including undetected microscopic disease beyond the margin at the time of RP, or circulating tumor cells in the blood. There is even some thinking that the scalpel can spread tumor cells during the surgery.
“Cure” is misleading
As with any cancer treatment, a prostate cancer patient naturally hopes for 100% success. If a urologist uses the word “cure” or simply implies that RP will be curative without explaining the chance of BCR, it is misleading. Instead, urologic surgeons should carefully prepare the patient for all possibilities, including BCR as well as side effects. It is my belief that to do anything less is irresponsible, because it leaves patients vulnerable to subsequent shock, fear and depression if there is BCR.
Focal therapy offers many advantages for patients who are good candidates for this approach. A rather ironic advantage is realistic expectations. When I speak with my patients about Focal Laser Ablation (FLA) I inform them that they must be meticulous about our follow-up monitoring because leaving untreated prostate tissue means BCR is always possible. Thanks to our top-shelf imaging, I can reasonably assure patients that I can treat all the cancer that is visible (I can also verify tumor ablation during treatment thanks to tissue thermography, and after treatment with contrast imaging). However, even the best MRI does not detect microscopic disease, or circulating tumor cells. Therefore, I strive to be clear about what FLA can offer: cancer control, but no claims of cure.
The idea that surgical prostate removal will cure a man’s prostate cancer is an overpromise. A realistic discussion leaves a patient free to make an informed choice about RP, and also to deal with BCR should it occur, without feeling betrayed and disappointed. As doctors, we should all be honest about the limits of what we can and cannot say about cure.
[i] “Surgery for Prostate Cancer.” American Cancer Society. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-surgery
[iii] Wadhwa H, Terris MK, Aronson WJ, Kane CJ et al. Long-term oncological outcomes of apical positive surgical margins at radical prostatectomy in the Shared Equal Access Regional Cancer Hospital cohort. Prostate Cancer Prostatic Dis. 2016 Dec;19(4):423-428.
[iv] Rogers C, Sammon JD, Diaz M, Sukumar S et al. Biochemical recurrence in 3,671 patients following robot-assisted radical prostatectomy. J Clin Oncol. 2011 May 20;29(15_suppl):e15048.