Outcome

Many men believe that if their prostate cancer is removed surgically and if there are no signs that the cancer has spread, then they are cured. This belief has been fostered by enthusiasts for prostate cancer surgery and by media presentations. The author of a 1996 Time magazine article about prostate cancer claimed that surgical treatment is ''the only one that can virtually guarantee a cureā€”if the cancer has not metastasized. . . . If the cancer has not spread beyond the prostate wall and the gland is removed, the cancer is gone. Period.''20

Unfortunately, that is not always true. Recurrence of prostate cancer following surgery is not a rare event. Two factors strongly influence the chance of recurrence: the age of the man and the stage of the cancer. The younger the man is at the time of surgery, the better his chances that the cancer will be curable. In one study of more than three thousand patients, the chances of cancer recurrence ten years after surgery were 24 percent in men 41 to 50; 29 percent in men aged 51 to 60; 34 percent in men 61 to 70; and 37 percent in men over 70. In another study in which all the men had PSAs between 4 and 6, only 13 percent of men aged 40 to 50 were considered to be not cured (defined by the pathological characteristics of the cancer), compared to 19 percent of men 51 to 60 and 26 percent of men 61 to 73. In this study, the age of the man was a better predictor of outcome than was the presurgical PSA level.21

The stage of prostate cancer is determined by the Gleason score and other pathological features, as described in Chapter 2. In one study that compared men who all had nonpalpable tumors, those who had a Gleason score of 6 or less and a PSA of 10 or less had only a 4 percent chance of cancer recurrence at ten years; by contrast, those who had a Gleason score of 7 or more and a PSA over 10 had a 27 percent chance of cancer recurrence. In another study of men followed for more than twenty years after surgery, those whose cancer was confined to the prostate at the time of surgery had a 27 percent rate of recurrence; those whose cancer was not so confined had an 83 percent rate of recurrence.22

An important question in research on the outcome of prostate cancer treatment is how the outcome is measured. Following surgery, the PSA level should drop to virtually zero, since the prostate has been removed and the amount of PSA made by other tissues is negligible. For this reason, it is common practice among urologists to assume that any PSA level of 0.2 or higher means that some cancer cells spread beyond the prostate at the time of surgery and that the cancer has recurred. Some urologists use a PSA of 0.4 or higher rather than 0.2 as an indication of recurrence. As will be discussed in Chapter 11, recurrence measured by PSA alone does not necessarily mean that the cancer will progress.

Another measure of cancer recurrence is that it has spread (me-tastasized) to the lymph nodes, bones, or other organs. Such cancers usually continue to spread and eventually lead to death if the man does not die from another cause. The ultimate measure of treatment for prostate cancer is how often the cancer kills. Another way to look at outcome is to assess whether treatment lengthens a patient's life beyond what he would have lived naturally or would have lived with

Table 2. Follow-up Studies of Recurrence Rates and Prostate Cancer Deaths Following Surgery for Prostate Cancer

St. Louis:

Houston:

Washington

Rochester, Minn.:

Baltimore:

Baylor

University

Mayo Clinic

Johns Hopkins

Number of men:

1,000

3,478

3,170

2,404

Average age:

63

61

66

58

Years of surgery:

1983-1998

1983-2003

1966-1991

1982-1999

Average follow-up:

4.4 years

5.4 years

5.0 years

6.3 years

% recurrence

measured by PSA

10 years:

25

32

48

26

15 years:

60

34

% metastases

10 years:

16

NA

18

10

15 years:

24

18

% dead because of

prostate cancer

10 years:

2

3

10

6

15 years:

18

10

source: G. W. Hull, F. Rabbani, F. Abbas, et al., Cancer control with radical prostatectomy alone in 1,000 consecutive patients, journal of Urology 67 (2002): 528-534; K. A. Roehl, M. Han, C. G. Ramos, et al., Cancer progression and survival rates, journal of Urology 172 (2004): 910-914; H. Zincke, J. E. Oesterling, M. L. Blute, et al., Long-term (15 years) results after radical prostatectomy for clinically localized (stage T2c or lower) prostate cancer, journal of Urology 152 (1994): 1850-57; M. Han, A. W. Partin, C. R. Pound, et al., Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy, Urologic Clinics of North America 28 (2001): 555-565.

source: G. W. Hull, F. Rabbani, F. Abbas, et al., Cancer control with radical prostatectomy alone in 1,000 consecutive patients, journal of Urology 67 (2002): 528-534; K. A. Roehl, M. Han, C. G. Ramos, et al., Cancer progression and survival rates, journal of Urology 172 (2004): 910-914; H. Zincke, J. E. Oesterling, M. L. Blute, et al., Long-term (15 years) results after radical prostatectomy for clinically localized (stage T2c or lower) prostate cancer, journal of Urology 152 (1994): 1850-57; M. Han, A. W. Partin, C. R. Pound, et al., Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy, Urologic Clinics of North America 28 (2001): 555-565.

prostate cancer if he had not been treated at all; both of these factors are discussed in Chapter 8.

Four large studies assessed the recurrence rates and cancer-related death rates following surgery for prostate cancer. Because the studies included men of different ages and with different stages of cancer and also used different outcome measures, it is difficult to compare them. The studies were carried out at Baylor College of Medicine in Houston, Washington University School of Medicine in St. Louis, the Mayo Clinic in Minnesota, and Johns Hopkins University in Baltimore. On the basis of follow-up periods averaging between 4.4 and 6.3 years, the percentage of men at ten or fifteen years following surgery who would have evidence of cancer recurrence as measured by PSA and by the spread of the cancer (metastases) was calculated. Deaths due to the prostate cancer were also estimated.

The results of the studies are summarized in Table 2 and are consistent with the results of most smaller studies. The Johns Hopkins study included more men who were younger (average age 58) and who had earlier, and thus more curable, stages of cancer. The number of men with nonpalpable cancer in the Johns Hopkins study was 44 percent, compared to only 7 percent in the Mayo Clinic study. In contrast to the other studies, the Johns Hopkins study excluded seventy-five men from follow-up because of evidence of advanced cancer and the need for additional treatment; such exclusions improve recurrence rates.

Given the data, what can be said about outcomes following prostate surgery? It seems evident that recurrence of prostate cancer is not a rare occurrence. At ten years after surgery, at least one quarter of men will have a recurrence of cancer as measured by PSA, and at least 10 percent will have metastases. At ten years, the death rate from prostate cancer is less than 10 percent. Fifteen years after surgery, there is more evidence of cancer, and the death rate from the cancer varies from 10 percent in younger men with less severe disease to 18 percent in older men with more severe disease.

Finally, the surgical treatment of prostate cancer has one striking advantage over all other treatments, which is that it provides men with the most information. After surgery, men know their exact Gleason score based on the entire cancer, not just the biopsy, and they know whether cancer has spread outside the prostate to seminal vesicles or surrounding lymph nodes. And because the entire prostate is removed at surgery, monitoring the postsurgical level of PSA provides an accurate and unambiguous measure of cancer recurrence. Thus, surgical treatment removes many uncertainties from the follow-up; the news may not necessarily be favorable, but at least the patient knows what the news is. Perhaps for these reasons a comparative study of the mental health of men treated by surgery, beam radiation, or watchful waiting reported that the men treated by surgery worried significantly less after treatment than men in the other two groups.23

CHAPTER

10 Ways To Fight Off Cancer

10 Ways To Fight Off Cancer

Learning About 10 Ways Fight Off Cancer Can Have Amazing Benefits For Your Life The Best Tips On How To Keep This Killer At Bay Discovering that you or a loved one has cancer can be utterly terrifying. All the same, once you comprehend the causes of cancer and learn how to reverse those causes, you or your loved one may have more than a fighting chance of beating out cancer.

Get My Free Ebook


Post a comment