Radical Prostatectomy Curbs Cancer Risks but Ups Adverse Events Compared With Waiting, Monitoring

By Marilynn Larkin

July 01, 2020

NEW YORK (Reuters Health) - Men with localized prostate cancer will likely have better oncological outcomes from radical prostatectomy (RP) versus deferring treatment, but they are also are more likely to experience urinary incontinence and erectile dysfunction, according to a new Cochrane Review.

"Given that men with localized prostate cancer are at relatively low risk for morbidity and mortality, there is a need to make difficult trade-offs between adverse events and disease-related progression," Dr. Robin Vernooij of the Netherlands Comprehensive Cancer Organization in Utrecht, told Reuters Health by email. "Therefore, patients and their healthcare providers should openly discuss the available evidence, using our review, on potential benefits and harms of different treatment options in the context of the patients' values and preferences and specific circumstances."

Dr. Vernooij and colleagues searched the literature through February 2020 for randomized controlled trials comparing RP versus deferred treatment. Localized prostate cancer was defined as T1-2, N0, M0 prostate cancer.

Definitions of both deferred treatments - watchful waiting (WW; observation) and active monitoring (AM) - are "often used inconsistently in the literature," the authors note.

As reported in the Cochrane Database of Systematic Reviews, four studies with 2,635 participants (average age between 60 to 70) were included. Three multicenter studies from Europe and the U.S. compared RP with WW (1,537), and one compared it with AM (1,098).

They found that RP probably reduces the risk of death from any cause (hazard ratio 0.79; moderate-certainty evidence). Based on overall mortality at 29 years, this corresponds to 764 deaths per 1,000 men with RP versus 839 deaths with WW.

RP probably also lowers the risk of death from prostate cancer (HR 0.57; moderate-certainty evidence). At 29 years, this corresponds to 195 deaths per 1,000 men with RP versus 316 with WW.

Further, RP may reduce the risk of progression (HR 0.43; low certainty evidence); at 19.5 years, this corresponds to 391 progressions per 1,000 men with RP compared with 684 with WW. RP also probably reduces the risk of developing metastatic disease (HR 0.56; moderate-certainty evidence); at 29 years, this corresponds to 271 metastatic diseases per 1,000 men for RP versus 431 with WW.

General quality of life at 12 years' follow-up is probably similar for both groups (risk ratio, 1.0; low-certainty evidence).

However, with RP, rates of urinary incontinence may be considerably higher (RR 3.97; low-certainty evidence), corresponding to 173 incontinent men per 1,000 versus 44 with WW. Findings were similar for rates of erectile dysfunction (RR 2.67; low-certainty evidence); at 10 years, this corresponds to 389 erectile dysfunction events per 1,000 versus 146 with WW.

Comparisons of RP with AM found that there are probably no differences in time to death from any cause or risk of death from prostate cancer, based on moderate evidence.

However, RP probably reduces the risk of progression (HR 0.39; moderate-certainty evidence); at 10 years, this corresponds to 86 progressions per 1,000 for RP versus 206 with AM), as well as the risk of developing metastatic disease (RR 0.39; moderate-certainty evidence).

Quality of life during follow-up was similar between the groups. However, urinary function was worse with RP.

Dr. Vernooij said the team will monitor the literature and update the review as new studies are published.

Dr. S. Adam Ramin, medical director of Urology Cancer Specialists in Los Angeles, noted in an email to Reuters Health, "Newer testing techniques...for biopsy specimen-containing prostate cancer cells may better predict possibility of cancer progression on AM. Therefore, incorporation of molecular testing in the evaluation of some patients with apparent low-risk features can better identify the true candidates for (this approach)."

"Unfortunately, some patients who chose AM develop a false sense of security and do not adhere to the follow-up plan," he said. "They may fail to return for their follow-up exams and eventually develop non-curable disease. Furthermore, there is no uniform protocol for follow-up of patients on AM."

"Many research articles with more than 15 years follow-up are based on the older technique of open radical prostatectomy," he added. "With the advent of robotic surgery, and consolidation of prostate surgery to surgeons with high levels of experience, the rates of incontinence and erectile dysfunction may be improved...and quality-of-life assessments...may be higher than reported in this study."

SOURCE: https://bit.ly/2Ai863i Cochrane Database of Systematic Reviews, online June 4, 2020.