Radical Prostatectomy Versus External Beam Radiation

Although early reports comparing the two modalities demonstrated a clear advantage for RP over external beam radiation therapy (EBRT),16'17 the studies were shown to have several flaws. More recent retrospective studies have evaluated the treatment outcomes of EBRT and RP in comparably staged prostate cancer patients. When stratified by preoperative biopsy grade, T stage and serum PSA, the rates of biochemical relapse-free survival and cause-specific survival for the two modalities were similar at 5 and 7 years post-treatment.18-23 However, since EBRT is a treatment that does not remove the cancer-harboring organ (the prostate), it is more likely to fail at >10 years than a modality that eliminates the source of the cancer (surgery). Accordingly, 7 years treatment outcomes may not be long enough to demonstrate any difference. Limited data have been presented that the addition of hormonal therapy may impact on the outcomes of high-risk prostate cancer treated by radiation. At present, there is no multimodality comparison available between radical prostatectomy and this group.

Although the absence of a randomized trial that directly compares the outcomes in patients with localized prostate cancer treated by RP versus EBRT, several observations can be made from available studies. Data suggest an advantage for surgery in treating clinically confined disease. When outcomes of surgery versus radiation were compared in high-risk cases (PSA >10, Gleason ^7) surgery was significantly proven to be better when negative margins were achieved, where in low-risk cases (PSA ^10, Gleason score ^6), positive margins after surgery were an adverse prognostic factor.18 In this era, where PSA-based early detection has led to the emergence of a new patient population with an increased proportion of organ-confined disease, surgery should be the best potentially curative option.

In addition, several studies suggested that a substantial percentage of patients with clinically localized prostate cancer would still harbor persistent cancer within the prostate after radiation therapy. Freiha etal. reported a 27% (39 out of 146 patients) positive biopsy rate 18 months or more following completion of radiation therapy, of which 19% subsequently developed metastases.24 Scardino et al. reported a post-irradiation positive biopsy rate of 22% with stage B1, with local recurrence developing in 58% of the patients with a positive biopsy by 5 years and in 82% by 10 years.25 The abovementioned studies further validate the argument for the importance of total surgical removal of the prostate gland. The challenge is whether this can be done with reasonable morbidity.

Radiation therapy has been promoted partly because of a perception that it does not affect potency. In a recent study, Mantz et al. noted an overall EBRT patient potency preservation of 71.3% versus 66.2% for patients who underwent nerve-sparing

Is Surgery still Necessary for Prostate Cancer?

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