Three position papers on locally advanced disease appeared in a recent issue of
European Urology open Science:
How To Manage T3b Prostate Cancer in the Contemporary Era: The Benefits of Surgery (2023)
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...To date, there are no evidence-based studies comparing RP with EBRT plus androgen deprivation therapy (ADT) for locally advanced disease. Several nonrandomized studies showed better survival outcomes after RP in comparison to EBRT plus ADT among well-selected patients (14). However, results from retrospective cohorts are inconsistent and biased. Both approaches are currently used, and surgery with pelvic lymph node dissection (PLND) is a strategy recommended for non–organ-confined PCa (1). It is noteworthy that the template for PLND is still under debate. Extended PLND provides better pathological staging without demonstrating differences in oncological outcomes in comparison to a limited template (15). However, extended PLND for PCa with aggressive pathological features on biopsy (GG 3–5) may yield a biochemical recurrence–free survival benefit (16)."
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How To Manage T3b Prostate Cancer in the Contemporary Era: Is Radiotherapy the Standard of Care? (2023)
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...To conclude, in the absence of level 1 evidence favoring RP over hormonoradiotherapy in the context of a multimodal approach, factors such as treatment complexity, toxicity, and ability to eradicate the micrometastatic disease load should be considered. When making a decision, in light of what has been discussed above, RT-based treatment may represent the best approach for patients with localized HR PCa"
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How To Manage T3b Prostate Cancer in the Contemporary Era: Referee Position (2023)
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...Where do we stand in 2023 regarding the management of patients diagnosed with cT3b prostate cancer? Is it possible to make any firm recommendation in terms of the “best” treatment available? The Scandinavian SPCG-15 trial has almost completed recruitment of patients with locally advanced prostate cancer. SPCG-15 is the only phase 3 trial randomising patients to a surgery- versus radiotherapy-based approach; the recently published characteristics for the first 600 patients in the study indicate that one-third overall will have T3b disease (16) and
this means that the debate will certainly not be closed even when definitive results become available. The best strategy is probably a patient-centred approach: patients and their families should be directly involved in the decision-making process, with acknowledgment of any treatment that has shown superiority for a hard endpoint, but in terms of impact on quality of life, the patient himself should have the last word. Professionals and care providers should ensure that the best technology for surgery and for radiotherapy is available in their centre, and that the best and most up-to-date systemic treatments are delivered."
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(See Full Texts for details.)
If I have a quibble, it's that
locally advanced isn't strictly identical to
high risk. For example, my G10 (5+5) biopsy without question put me in the high-risk group; however, there were several indications that my cancer was not locally advanced--defined as having left the prostate capsule via EPE, BNI, or SVI or via local lymph-node metastasis. This nonetheless conforms to a takeaway message that
cases vary considerably as to whether surgery, either alone (as in my case) or with follow-up adjuvant therapy can provide permanent oncological cancer control.
In my case, my good imaging results (CT and X-ray) suggesting prostate confinement, PSA < 10, negative bone scan, 6-month uro visits, numerous (previous) negative biopsies, and indications of a low tumor burden (2/14 positive cores), increased my hope that we had caught my PCa very early and that I had a reasonable chance of avoiding RT + 2 years of ADT following surgery despite a Gleason Grade Group of 5.
Djin