Originally published 2/1/2017
It was true when we posted the blog below in 2017, and it’s still true now: surgical removal of the prostate gland does not guarantee a cure for prostate cancer (PCa). What it does offer, in the words of expert European urologists, is “a high chance of cure.”[i] In fact, published rates of recurrence at 5 years after radical prostatectomy (RP) are as high as 20%, or one out of five cases.[ii] Yet many newly diagnosed patients find assurance in the idea that cutting out the prostate gland will get all the cancer out.
Over the years, our blogs have emphasized the importance of matching the treatment to the disease. Men with low-risk PCa will have roughly equal cancer control rates regardless of which treatment they choose: surgery, radiation, focal therapy, etc.—even Active Surveillance. However, as the degree of risk rises, the rates of long-term cancer control begin to fall (failure is generally defined as rising PSA after surgery). According to Furubayashi, et al. (2017), in their study of 481 patients who had RP and were followed for an average of 54.1 months, the 5-year PSA failure-free rate for low-risk PCa was 96.5%, for intermediate-risk PCa was 88.9%, and for high-risk disease was 72.6%. As you can see, over a quarter of high-risk patients experienced recurrence as indicated by PSA.
The standard D’Amico assessment of risk level is based on three clinical factors: tumor stage, Gleason score, and PSA. The Furubayashi paper focuses on the 222 patients who had intermediate-risk disease, defined as stage T2b or Gleason score of 7 or PSA level >10 and ≤0 ng/ml. Whether a patient had one, two, or all three of the risk factors determined the likelihood of PSA failure. Based on statistical analysis, the authors note, “The 5-year PSA failure-free rate in the one, two and three intermediate risk factor groups was 94.9%, 88.4%, and 49.0%.”[iii]
It’s clear, then, that the more information a PCa patient has about his disease, the more realistic his expectations must be in choosing a treatment. This means gaining the most accurate diagnosis through multiparametric MRI and real-time MRI targeted biopsy, as well as taking into account a patient’s age, family history of breast/prostate cancer, and lifestyle preferences. It also means detecting PCa early, when the greatest number of treatment options are open. We recognize that none of today’s PCa treatments come with an ironclad guarantee, but we also recognize that knowledge is power, and can greatly increase the likelihood that PCa can be conquered…for life.
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.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Kesch C, Heidegger I, Kasivisvanathan V, Kretschmer A et al. Radical Prostatectomy: Sequelae in the Course of Time. Front Surg. 2021 May 28;8:684088.
[ii] Cooperberg MR, Hilton JF, Carroll PR. The CAPRA-S score: a straightforward tool for improved prediction of outcomes after radical prostatectomy. Cancer. (2011) 117:5039–46. 10.1002/cncr.26169
[iii] Furubayashi N, Negishi T, Iwai H, Nagase K et al. Biochemical failure after radical prostatectomy in intermediate-risk group men increases with the number of risk factors. Indian J Urol. Jan-Mar 2017;33(1):64-69.
[iv] “Surgery for Prostate Cancer.” American Cancer Society. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-treating-surgery
[vi] 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.
[vii] 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.