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UROSCAN
Year : 2010  |  Volume : 26  |  Issue : 4  |  Page : 604-605
 

Does radical prostatectomy prevent deaths from prostate cancer?


Department of Urology, Christian Medical College Hospital, Vellore 632002, India

Date of Web Publication31-Dec-2010

Correspondence Address:
Arabind Panda
Department of Urology, Christian Medical College Hospital, Vellore 632002
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Panda A, Kumar S, Kekre NS. Does radical prostatectomy prevent deaths from prostate cancer?. Indian J Urol 2010;26:604-5

How to cite this URL:
Panda A, Kumar S, Kekre NS. Does radical prostatectomy prevent deaths from prostate cancer?. Indian J Urol [serial online] 2010 [cited 2019 Oct 16];26:604-5. Available from: http://www.indianjurol.com/text.asp?2010/26/4/604/74482

Prostate Cancer-Specific Mortality After Radical Prostatectomy for Patients Treated in the Prostate-Specific Antigen Era. Stephenson A.J, Kattan M.W, Eastham J. A, Bianco Jr F.J, Yossepowitch O, Vickers A J, Klein E.A, Wood D.P, Scardino P.T. J Clin Oncol. 2009 Sep 10; 27(26):4300-5.



   Summary Top


Stephenson et al . have followed a cohort of 6,398 patients who underwent radical prostatectomy (RP) for localized prostate cancer over a period of 18 years, for death attributable to prostate cancer. They have also developed a nomogram based on the primary and secondary Gleason grade, prostate-specific antigen, and clinical stage to predict the 10- and 15-year probability of dying from prostate cancer after RP. External validation was done with a separate cohort of 6,279 patients. Overall, the 15-year prostate cancer specific mortality (PCSM) was 12% and the all cause mortality was 38%. The 15-year PCSM for good risk patients (46% of the study population) was 2%, 10% for intermediate risk, and 19% for high risk. Multivariate analysis revealed only primary and secondary Gleason grade and increasing serum PSA were directly related to PCSM while the year of surgery had an inverse relation with contemporary patients faring better.


   Comments Top


While the methodology and the study are statistically elegant, many questions arise. It would have been more relevant to compare this cohort to a similar group assigned to nonsurgical management. The authors compare the PCSM in their own cohort of screen-detected prostate cancer with the PCSM of an unscreened group (12- 15% vs. 50-70%). Ref.(2) that has been quoted to support this figure in the text only mentions a PCSM of 24% in the conservatively managed, nonscreen-detected prostate cancer patients. [1] How the figure of 50-70% was arrived at is not clear. Prostate cancer is a clinically heterogeneous disease. Screening-detected cancer is usually low grade and low risk, which in its normal course may never have manifested. Clinically manifest unscreened cancer is an aggressive high-risk disease with a high risk of death. Significantly around half of all the patients in the cohorts were good risk. Apart from the inherently low mortality associated with such cancers, stage migration ("the Will Rodgers effect") would also be likely to contribute to the better PCSM in the study group. [2] Galper et al . in a separate study confirmed the effect of stage migration, and found that biochemical recurrence after RP in the PSA screening era is less than that in the pre-PSA era. [3] Lead time bias may similarly lead to an apparent reduction in PCSM at 15 years. It will be interesting to know the percentage of biochemical recurrence and the survival of these patients beyond 15 years. Finally, critical to the calculation of PCSM is an accurate determination of the cause of death. Newschaffer et al . estimate that inaccurate reporting of prostate cancer deaths on death certificates may be as high as 20% particularly in patients who have died following a diagnosis of prostate cancer aged 67 years or older. Such systematic reporting bias can yield important distortions when reporting cancer statistics. [4]

As Jewett stated "The quandary in prostate cancer: Is cure necessary in those for whom it is possible, and is cure possible in those for whom it is necessary?". [5] The natural history of prostate cancer is yet to be clearly delineated. The treatment is still evolving and the jury is out on PSA screening. Even the most ardent supporters of PSA screening have to admit that it leads to a significant incidence of overdiagnosis. [6] The challenge is to develop better biomarkers to identify the high-risk cancers to separate the wolf from the sheep. Till then it may be prudent to avoid physician initiated screening. Better designed randomized trials addressing both survival and quality of life are required to lay the controversy to rest.

 
   References Top

1.Cuzick J, Fisher G, Kattan MW, Berney D, Oliver T, Foster C S, et al. Long term outcome among men with conservatively treated localised prostate cancer. Br J Cancer 2006;95:1186-94.  Back to cited text no. 1
    
2.Feinstein AR, Sosin DM, Wells CK. The Will Rogers phenomenon. Stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. NEJM 1985;312:1604-08.  Back to cited text no. 2
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3.Galper SL, Chen Ming-Hui, Catalona WJ, Roehl KA, Richie JP, D'Amico AV. Evidence to support a continues stage migration and decrease in cancer specific mortality. J Urol 2006;175:907-12.   Back to cited text no. 3
    
4. Newschaffer CJ, Otani K, McDonald MK, Penberthy LT. Causes of death in elderly prostate cancer patients and a comparison non prostate cancer cohort. J Natl Cancer Inst 2000;92:613-21.   Back to cited text no. 4
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5. Montie JE, Smith JA. Whitmoreisms: memorable quotes from Willet F. Whitmore, Jr, M.D . Urology 2004;63:207-09 .  Back to cited text no. 5
    
6.Welch H G, Albertsen P C. Prostate Cancer Diagnosis and Treatment After the Introduction of Prostate-Specific Antigen Screening: 1986 -2005. J Natl Cancer Inst 2009;101:1325-9.  Back to cited text no. 6
    




 

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