Steven Joniau, MD, PhD

University Hospitals Leuven

Leuven

Belgium

Surgery for localized, locally advanced and

high risk prostate cancer

117,328 patients with prostate cancer

26,410 low risk (22.5%)

cT1-T2, PSA <10 ng/ml AND Gleason 2-6

26,611 intermediate risk (22.7%)

cT1-T2 AND PSA 10 - <20 OR Gleason 7

30,159 high risk (25.7%)

cT3 or PSA 20-50 or Gleason 8-10

Non-curatively treated

Rider JR et al. Eur Urol 2012 2

Who dies of PCa? Natural evolution of non-curatively treated PCa

10%

20%

35-40%

Rider JR et al. Eur Urol 2012

All ages <65 years 65-75 years >75 years

Prostate cancer Cardiovascular Other

Lo

w r

isk

M

ed

ium

ris

k

Hig

h r

isk

Who dies of PCa?

Natural evolution of non-curatively treated PCa

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Complete removal of the prostate, seminal vesicles, and pelvic lymph nodes (when necessary)

• With minimal perioperative morbidity, no blood transfusions, and early return to normal activities

• No positive surgical margins

• No long-term loss of continence or potency

Goals of modern radical prostatectomy (RP)

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PIVOT Trial

PSA detected

RP vs observation for localised PCa

RP did not significantly reduce all-cause or PCa-specific mortality as compared

with observation

Wilt TJ et al. N Engl J Med 2012;367:203-13

PCa-specific mortality

5

Low-risk PCa

PCa specific mortality

6

Overall mortality

Wilt TJ et al. N Engl J Med 2012;367:203-13

PCa specific mortality

7

Overall mortality

Intermediate risk PCa

Wilt TJ et al. N Engl J Med 2012;367:203-13

PCa-specific survival

~45%

~17%

P= 0.05

High risk PCa

8 Wilt TJ et al. N Engl J Med 2012;367:203-13

Briganti A, Spahn M, Joniau S et al. for EMPaCT Eur Urol 2013

Only men ≤ 59 years old had higher risk of PCa-related

death than death-related to other causes

10%

<10%

Prostate cancer Other

MORTALITY RATES FOR SURGICALLY TREATED

HIGH-RISK PCa

Cooperberg M, et al. AUA 2015 – Data from CAPSURE

Which treatment for which cancer?

Up untill 2007, Low-risk PCa was too often actively treated,

while high-risk PCa was too often undertreated 10

Cooperberg M, et al. AUA 2015 – Data from CAPSURE 11

After 2007, Low-risk PCa was more often treated with AS/WW,

while high-risk PCa was more often actively treated!!!

Which treatment for which cancer?

Cumulative incidence function estimates of cancer

specific and other cause mortality survival curves

(n=34 515), stratified according to treatment type.

Sooriakumaran P et al. BMJ 2014;348:bmj.g1502

M+ or N+ or T4 or

PSA>50 Low Intermediate High

RP

RT

12

Sooriakumaran P et al. BMJ 2014;348:bmj.g1502

13

Cumulative incidence function estimates of cancer

specific and other cause mortality survival curves

(n=34 515), stratified according to treatment type.

Cooperberg M, et al. AUA 2015 – Data from CAPSURE 14

HIGH-RISK 15-Y

EA

R C

AN

CE

R M

OR

TA

LIT

Y

- Retrospective analysis of data from the Norwegian Prostate Cancer Registry, 2004-2005

- 3486 patients, RP (n = 895), EBRT +/- ADT (n = 1339), or no local treatment (n = 1252)

- Clinical stage T1-T3, PSA ≤100 ng/ml, D’Amico risk group stratification

- Comparison of active local treatment (RP, RAD) versus no active local treatment (NoLocTrt)

PCa mortality

Other cause mortality

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HIGH-RISK

Big surgeon, big incision…?

• NO difference in positive surgical margins

• NO difference in incontinence

• SMALL difference in erectile dysfunction in favor of RALP

The changing role of surgery

• Properly performed, RP is a highly effective treatment

for high-risk prostate cancer in men with a sufficiently long life expectancy to justify the risks

• Outcomes of RP – cancer control, peri-op complications, and long-term urinary and sexual function – are directly related to the skill and experience of the surgeon, but not to the technology used (open v. robot-assisted)

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