In the urologic world, there is a longstanding bias that surgical removal of the prostate gland, or radical prostatectomy (RP), is the preferred treatment for prostate cancer (PCa). It is based in the outdated belief that all PCa is a) multifocal, and b) likely to spread beyond the gland if untreated. Thus, it seemed logical that taking the gland out was the best way to handle the disease.
In the best of conditions, RP is not 100% effective. Anywhere from 5-15% of low risk patients will experience recurrence as late as 10 or more years after surgery. The odds of recurrence are significantly higher for intermediate-to-high risk patients who are recommended for RP. Tragically, such patients are often found to have positive surgical margins at the time of treatment, meaning the cancer has already penetrated the prostate capsule so there is greater probability of spread. Patients with positive margins are often prescribed additional treatment in the form of either radiation therapy (RT), androgen deprivation therapy (ADT or hormones) or both (RT + ADT), in hopes of controlling the cancer.
The most common side effect risks of RP are urinary incontinence (leaking or dripping urine) and erectile dysfunction (ED). Reported side effect rates vary widely; how long it takes before the patient regains baseline urinary and sexual function is unpredictable. A new published study demonstrates that RT and/or ADT after surgery increases both the occurrence rates and duration of these side effects.[i] The observational study followed 13,150 patients who had RP from 1992 to 2013. Most of them had RP alone; 905 had RP + RT; 407 had RP + ADT; and 688 had RP + RT + ADT. The authors compared the impact of additional treatments vs. RP alone. They collected annual data by administering self-report questionnaires on urinary continence, potency and quality of life (QOL).
The following table offers a summary of the patient self-reports at 3 years after treatment:
|3-year results||RP only||RP + RT||RP + RT + ADT|
|Probability of continence||91%||87%||80%|
|Probability of potency||58%||40%||23%|
|Probability of QOL score ?83.3%||68%||57%||48%|
Given the obvious detrimental effects of secondary treatments on quality of life following RP, the article’s conclusion was, “Patients with high-risk disease should be counseled before RP on the potential net impairment of functional outcomes due to multimodal treatment.” While this is an excellent recommendation, the reality is that such counseling occurs without actual knowledge of the size, location and extent of the patient’s cancer. However, there is a solution to that problem.
At the Sperling Prostate Center, we use multiparametric MRI (mpMRI) before prostate biopsy for an image-based risk assessment. If a biopsy is needed, we offer real-time MRI targeted biopsy for the most accurate diagnosis. Even before biopsy, however, our mpMRI has the ability to detect capsular invasion and extracapsular extension. If it is evident that the tumor has already penetrated the margin and invaded the lymph nodes – which can also be ascertained by mpMRI – the patient and his doctor can discuss appropriate treatments that don’t include RP, in order to maximize cancer control while preserving the highest quality of life.
[i] Adam M, Tennstedt P, Lanwehr D, Tilki D et al. Functional Outcomes and Quality of Life After Radical Prostatectomy Only Versus a Combination of Prostatectomy with Radiation and Hormonal Therapy. Eur Urol. 2017 Mar;71(3):330-336.