Postoperative Treatment After A Radical Prostatectomy
by William J. Catalona, MD
Doctors and patients alike hope that removing the prostate, a radical prostatectomy (RP), will be a successful, life-long treatment for prostate cancer.
Still, patients need to be informed of recommended further testing after the surgery and preventative postoperative treatments connected to the results of this testing.
Before surgery, at the time of reviewing the pathology report from the operation, and at each follow-up visit; the doctor should gently remind the patient that recurrence of the cancer is always a possibility. Therefore, it is very important for the patient to maintain a regular schedule of follow-up visits.
I recommend follow-up for 15 years with a PSA blood test every 6 months and a DRE (digital rectal exam) annually.
"Patients should understand the vocabulary."
Also, patients should be aware of recurrence prediction tables and understand the vocabulary associated with the risk for recurrence: vascular/lymphatic invasion, positive margins, extracapsular tumor extension, seminal vesicle invasion, tumor volume, lymph node status and preop PSA.
Vascular/lymphatic invasion means that the pathologist identified cancer cells growing into blood vessels or lymphatic channels. This finding indicates a higher risk for cancer recurrence at a site distant from the prostate gland.
Positive margins means that cancer cells were growing at the edge of the surgical specimen, indicating a possibility (although not a certainty) that some cancer cells may have moved into the tissues surrounding the prostate gland. In this case, there is a greater risk (not a certainty) for a local recurrence in the "bed" of the prostate gland.
Extracapsular tumor extension means that tumor cells are seen growing in the tissue surrounding the prostate. It is possible to have extracapsular extension with negative (clear) margins if a rim of additional tissue is removed with the prostate gland. However, it is also possible to have extracapsular extension with positive (cancerous) surgical margins.
In either case, the risk for tumor recurrence is higher than if the cancer were completely contained within the prostate gland, but the risk is higher when there are both extracapsular extension and positive surgical margins.
Seminal vesicle invasion means that the tumor has spread to the seminal vesicles, which are attached to the prostate gland. Although the seminal vesicles are usually removed completely with the prostate gland during a radical prostatectomy, the fact that the tumor cells have spread to involve them is associated with a greater risk of tumor recurrence.
"I recommend follow-up for 15 years."
Lymph node involvement is associated with recurrence of the prostate cancer in more than 85% of patients. There is also a greater risk of recurrence if the volume of cancer in the prostate is large (i.e., if most of the prostate gland has been replaced by cancer) or if the preoperative PSA level is high. (The PSA level usually is an indication of how much cancer tissue is present.)
If any of the above findings are present in the radical prostatectomy speciment, then additional postoperative treatment should be considered in the form of radiotherapy , hormonal therapy or chemotherapy.
Radiotherapy is best suited for patients with positive margins and/or extracapsular tumor extension, because they are more likely to have a tumor recurrence in the bed of the prostate gland.
However, not all patients with these findings require radiation therapy, and, in fact, most will not have a tumor recurrence, even without radiotherapy. Thus, these patients have the option of having radiotherapy as a preventive measure or, alternatively, they can opt to monitor their postoperative PSA levels and have radiotherapy only if the PSA begins to rise.
With postoperative radiotherapy, the earlier the treatment, the better, but current evidence suggests that not much is lost by waiting to see if the PSA level rises and then instituting radiotherapy right away.
Radiotherapy is also a possible treatment for men with seminal vesicle invasion, vascular invasion, lymph node metastases, and a post-operative PSA of more than 0.2, but it is less likely to solve the problem completely, because these adverse findings are more likely to be associated with recurrence at a site distant from the prostate gland.
Hormonal therapy (intermittent or continuous) and/or chemotherapy are perhaps better treatments for: vascular invasion, lymph node metastases, and failure of PSA to become undetectable, because these findings are more likely to be associated with more widespread tumor recurrence. These two systemic forms of therapy work throughout the body and are more likely to exert their effect on all tumor cells, regardless of where they are located.
Other factors to consider in postoperative treatment decisions are: a patient's age, original pathological features (Gleason grade and tumor volume) and preoperative PSA levels, other medical conditions, as well as the time pattern in the increase of PSA (how long after surgery the PSA begins to rise and how fast and how much the PSA has risen).
Each of the treatments has its pros and cons.
Radiotherapy has a good cure potential, but the possible side effects are proctitis (injury to the rectum that could cause chronic diarrhea or bleeding), cystitis (injury to the bladder that could cause irritability or bleeding), impotency, incontinence, and damage to the bone marrow that could compromise the ability to receive chemotherapy in the future. None of these side effects is life threatening.
Hormonal therapy is a treatment to slow the progression of the cancer, but it is not a cure. Still, for the most part, the side effects are mild and reversible. One factor to consider is the effect of prolonged, continuous androgen deprivation (hot flashes, osteoporosis, loss of muscle mass, increase in body fat, lack of energy).
Chemotherapy is a method for slowing the progression of the cancer, but, for prostate cancer, chemotherapy is not as effective as it is for some other tumors, and the more severe side effects also should be considered.
Salvage Radiotherapy (see Q&A's this issue) is recommended for rising PSA after a RP. Hormonal therapy is recommended when salvage radiotherapy is not possible or desired by the patient or when salvage radiotherapy has failed to control the tumor. Chemotherapy is usually reserved for patients who no longer respond to hormonal therapy; however, chemotherapy is now being used earlier in combination with other treatments in patients at very high risk for tumor recurrence.
Experimental therapies (immunotherapy, gene therapy, growth factor inhibitors, etc.) do exist, but they are still premature in most instances and the knowledge about their effectiveness and their side effects is limited.
Timing for the beginning of hormonal therapy in prostate cancer seems to be important. Studies have pointed to the benefits of initiating hormonal therapy earlier in the treatment of prostate cancer. The greatest benefits may be gained when only tiny amounts of prostate cancer are present.
Radiotherapy is performed by specialists called radiation oncologists. Chemotherapy is overseen by medical oncologists. Hormonal therapy may be administered by urologists, radiation oncologists, and medical oncologists.