PSA recurrence, metastatic disease, and prostate cancer death
have decreased dramatically in men treated in the PSA era (after 1992).
Before 1982, not many men wanted to undergo radical prostatectomy, because the cure was considered as bad as, if not worse than, the disease. Impotence was universal, and incontinence was more common than not. The operation was also notorious for the excessive bleeding that went along with it. But then surgeon Patrick C. Walsh, M.D., discovered the location of the nerves responsible for erection. They were where no one had suspected – outside the prostate – and did not necessarily have to be removed along with the prostate. He also developed techniques to create a "bloodless field," to reduce the terrible blood loss and allow the surgeon better vision of the anatomic terrain during the procedure which, in turn, produced a dramatic reduction in incontinence as well as impotence. These discoveries marked the birth of the "nervesparing" radical prostatectomy, the "Walsh Procedure," which has become the gold standard for treatment of prostate cancer.
Patrick Walsh wants his patients to know that without their feedback – more than 50,000 PSA reports over the years – he wouldn't be able to provide these results. "You sent them in and I added them to the database. As a result, it is possible to be more precise in charting the future for the next generations of men who will be undergoing surgery. This is a wonderful legacy that you have created."
At the 30-year anniversary of this landmark discovery, scientists Stacy Loeb, Walsh, Jeffrey Mullins, Zhaoyong Feng, Bruce Trock and Jonathan Epstein examined the results of 4,569 radical prostatectomies performed between 1982 and 2011 by Patrick Walsh at Johns Hopkins; their results will be published in the December 2012 Journal of Urology. "The average followup was 10 years," says Loeb, now at New York University. "Our most important finding was that men treated after 1992, when PSA screening was introduced did much better than the men treated between 1982 and 1991. Because screening allowed men to be diagnosed earlier, men from the PSA era were far more likely to have organ-confineddisease (72 percent versus 37 percent) and less likely to have involvement of the seminal vesicles and lymph nodes. As a result, PSA recurrence, metastatic disease and prostate cancer death occurred much less frequently among men treated in the PSA era." These results are particularly timely in light of the recent controversial recommendation from the United States Preventive Services Task Force that PSA testing (see story) should not be done.
Tumor stage and grade were also important factors in predicting the long-term prognosis after surgery. "Based on this wealth of information and the lengthy follow-up, we now have long-term prognostic information that can be shared with patients," she adds. These results are in line with another recent study by Loeb and collaborators from the European Randomized Study of Screening for Prostate Cancer (ERS PC). In this large, randomized study, scientists found that men who had PSA screening had better outcomes after surgery than men who were not diagnosed through screening. "These studies both highlight how screening and curative treatment go hand in hand," says Loeb. In conclusion, "we found excellent longterm cure rates with contemporary anatomic radical prostatectomy," Loeb says.
"These results are encouraging for men who have undergone surgery for prostate cancer, showing a low risk of the disease spreading or causing death many years afterward." The authors hope these historic data will also provide a useful benchmark for comparison with new forms of treatment.
Walsh notes that this study would not have been possible without the participation of his patients, "who faithfully reported their status year after year, giving us more than 50,000 PSA reports." To his patients, he has this message: "You sent them in and I added them to the database. As a result, it is possible to be more precise in charting the future for the next generations of men who will be undergoing surgery. This is a wonderful legacy that you have created."
| The Bottom Line
The study's most important finding was that men treated after 1992, when PSA screening was introduced, did much better. Because screening allowed men to be diagnosed earlier, these men were far more likely to have organ-confined disease. As a result, PSA recurrence, metastatic disease and prostate cancer death occurred much less frequently among men treated in the PSA era.