Cancer Control After Radical Prostatectomy
Radical prostatectomy cures the vast majority of men with cancer confined to the prostate. It
also cures most men even if cancer has reached or penetrated the prostate wall, if the tumor cells
are pretty well differentiated (a Gleason score of 6 or lower), and if surgeons are able to remove
all the cancer (if the surgical margins are "clear," or negative). And preserving potency -- by not
removing one or both of the nerve bundles adjacent to the prostate, which are responsible for
erection -- does not make cure less likely; in fact, the odds of cure are just as high.
However, when a high-grade tumor (Gleason 8 or higher) has penetrated the prostate wall, or
when the cancer has reached the seminal vesicles, the chances for a cure are not as certain.
These and other findings have just been confirmed by a massive, long-term study of 1,623 men
with clinically localized (estimated before surgery to have stage T1, T2, or T3a) disease. Cure
was defined by the "gold standard" -- an undetectable level of PSA after surgery. (PSA, or
prostate-specific antigen, an enzyme made by the prostate, is a highly sensitive measure of cancer
recurrence; if the prostate is no longer in the body and PSA is being made at detectable levels,
then some prostate cancer cells must remain in the body.)
The men, operated on between 1982 and 1995, underwent anatomical radical retropubic
prostatectomy and pelvic lymph node dissection; the operations were all done by the same
surgeon, Patrick C. Walsh, M.D., who developed this "nerve-sparing" procedure. Five years
after surgery, only one percent of these men had died from prostate cancer, and at 10 years, only
7 percent had.
At 10 years after surgery, nearly 70 percent of them remained cancer-free, with no trace of PSA
in the bloodstream; 18 percent had experienced a lone elevated PSA level; 8 percent had local
recurrence of cancer (some of these men then underwent external-beam radiation treatment,
which seemed to work: Their PSA level again dropped to the undetectable range and has stayed
there for at least two years); and 9 percent had distant metastases.
The higher a man's clinical stage, Gleason score (particularly, 8 or higher), PSA before surgery
(particularly, higher than 20), and pathologic stage (determined when a pathologist examines the
actual tissue removed during surgery), the greater this odds of recurrence.
Interestingly, having positive surgical margins didn't dramatically alter the prospects of cure in
men with Gleason grades of 6 or lower, even if the cancer had reached the edge where the tumor
was removed. (For more on positive margins, click here.)
However, in men with Gleason grades of 7 or higher, having a positive surgical margin may raise the risk of
recurrence. Longer follow-up study of these men is needed to determine this, Walsh says.
Why doesn't radical prostatectomy cure every man? It's probably because the cancer has
escaped the prostate before surgery, to the point where surgeons can't remove it all, in the
form of invisible, impossible-to-detect, distant metastases -- microscopic, malignant flecks that
have already left the main tumor (even before diagnosis), casting themselves into the
bloodstream like dandelion seeds in the wind, taking root elsewhere in the body. (Yet, although
surgery can't cure prostate cancer in these men, it reduces the many complications of advanced
disease and may prolong survival in some men -- click here for more.)
"The bottom line of this long-term study," concludes Walsh, "is that surgery cures the vast
majority of men with tumors that are confined to the surgical specimen. Fortunately, today with
improved means for early detection, this means that most men diagnosed with prostate cancer
can be cured with surgery."
"PSA Following Anatomical Radical Retropubic Prostatectomy: Patterns of Recurrence and
Cancer Control." Urologic Clinics of North America, Vol. 24, No. 2, May 1997. Charles
R. Pound, Alan W. Partin, Jonathan I. Epstein, and Patrick C. Walsh.