New data from a study recently published in the New England Journal of Medicine are suggesting that surgery may improve survival in men diagnosed with prostate cancer who are younger than age 65 years or with intermediate-risk disease.

Researchers reported that the risk of metastases and the need for additional treatment was reduced among men who underwent radical prostatectomy (RP) compared with watchful waiting (WW).1

Researchers reviewed the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4), which randomly assigned 695 men with early prostate cancer to treatment with RP or WW with no initial treatment.

In this latest analysis, researchers examined data from 23.2 years of follow-up and found that 200 of 347 men in the RP group had died. The number of deaths was significantly higher in the WW group, where 247 of 348 men had died. In the surgery group, 63 of the deaths resulted from prostate cancer compared with 99 in the WW group.

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“The most important result is that we showed that you need to follow men for a very long time to see the whole picture. Short-term studies could be misleading,” said study coauthor Jennifer Rider, MD, an assistant professor in the Department of Epidemiology at Harvard School of Public Health in Boston, MA.

“Surgery appears to be most beneficial for men who are younger at diagnosis with the longest life expectancies,” said Dr. Rider in an interview with ChemotherapyAdvisor.com. “The most important message is that prostate cancer has a long natural history and this study provides some insight into what happens to men over the long-term.”

New Imaging Technique May Better Determine WW Candidates

All of the men in this study were enrolled between October 1989 and December 1999 at 14 centers in Sweden, Finland, and Iceland, and before the current refinements in the use of prostate-specific antigen (PSA) testing. In the last 5 years, new algorithms have helped better guide which men may be the best candidates for WW.

In just the past 9 months, a new imaging technology (UroNav, Invivo, Gainesville, FL) has become available that may help even better define which patients may be the ideal candidates for WW or RP. The new technology fuses images from magnetic resonance imaging (MRI) with ultrasound to create a detailed, three-dimensional view of the prostate.

“PSA leads to overdiagnosis, but a blood test never kills anyone. [What is important] is what happens after we get the number,” said prostate cancer surgeon Gopal Gupta, MD, from Loyola University in Chicago, IL.

He said this new imaging technique may revolutionize how prostate cancer is diagnosed. First, the patient undergoes an MRI exam before undergoing a biopsy. The MRI is then fused with ultrasound imaging during the biopsy. The system employs GPS technology to guide the biopsy needle to the lesions detected by the MRI, leading to significantly fewer needle biopsies.

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Dr. Gupta said that, compared with traditional biopsy techniques that randomly sample the prostate, this MRI-based technique may help prevent physicians from missing hard-to-find and often aggressive prostate cancers. He said traditional biopsies lack precision, which can lead to both undertreatment and overtreatment. If the biopsy fails to identify an aggressive tumor, the patient may be undertreated. Conversely, a patient may undergo surgery or radiation for a tumor that likely would grow too slowly to endanger the patient during his expected lifetime.

“A paradigm shift is what is happening. We can find areas of suspicion with the MRI so [clinicians] can determine which area is of most concern and then fuse that information into a targeted biopsy,” Dr. Gupta told ChemotherapyAdvisor.com. “It is a rational biopsy. Prostate sizes vary among men of different ages. Some have ones the size of an orange and some have prostates the size of walnuts. So you have a high chance of missing tumor[s] in a larger prostate because you might be undersampling.”

Reference

  1. Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med. 2014;370(10):932-942.