Surgery is an option. It’s not a good option for high-risk cases.…but it’s an option. It’s also an option for low-risk cases…also not a good option (for very different reasons), but an option.
Why is it not a good option for high-risk cases? The answer lies is understanding what “risk groups” mean, which I don’t think many people know.
The NCCN, the National Comprehensive Cancer Network, has been publishing Clinical Practice Guidelines in Oncology for prostate cancer since 1996, and since at least 2002 (this is the oldest I’ve found online), those Guidelines—which are the basis for the standard of care for ALL cancer patients—are based on two important inputs which are unique to each patient: risk group, and life expectancy.
You’ve probably seen many posts here at HW/PC about
“risk group.” It is so important that it is the very first thing listed
in the HW/PC sticky thread Newly diagnosed with PC? – read this thread first
, and called out as “Step #1 for all PC newcomers”
to fully understand what their “risk group” or “risk category” is BEFORE making ANY decisions on treatment. It's also why the sticky thread later states that the Step #0
is having the biopsy slides read by a prostate pathology expert...because you damm sure want to get the best possible, most accurate understanding of your risk group before making treatment decisions. Many people use the NCCN Guideline information, and have for years, without really
knowing “risk of what…?”
The answer is risk of cancer recurrence following initial therapy.
Since at least 2002, there were three risk groups used for risk stratification: low-risk, intermediate-risk and high-risk of recurrence. Today there are also very low-risk and very high-risk groups, in addition to the favorable-intermediate and unfavorable-intermediate, for a new total of 6 groups. Using these risk stratification categories as guidance, physicians can optimize cancer survival while minimizing treatment-related morbidity.
Back to the original (re-worded) question: “Is surgery an option for cases with a high-risk of recurrence following initial therapy?”
Maybe it’s becoming obvious now. The guidance that surgeons have followed is that if they
open you up and see
, visually, that there has been spread outside of the prostate, then they simply stop the procedure and close-up without even removing the prostate. It makes absolutely no sense to proceed with surgery with the knowledge this patient is going to need radiation therapy; surgery does absolutely nothing from a cancer-control standpoint for PC which is outside the gland. In other words, they already realize that this is a case where “recurrence” would be known to occur if the prostate were removed. Surgery is (basically) ONLY useful if the cancer is contained in the prostate. In this hypothetical case where PC spread was found during surgery before removing the prostate, there is absolutely no reason
to compound the patient’s problems (morbidity) , making them deal with the terrible side effects of surgery knowing that they will also have to undergo the worsened side effects salvage radiation therapy…because the radiation therapy is going to be needed one way or the other, and primary RT side effects and nowhere as bad a secondary RT side effects.
In cases where both the dominant and non-dominant Gleason patterns are 4 or 5, the statistical likelihood of spread outside the prostate is high. More specifically, the higher the percentage of Gleason grade 4 cells in the biopsy sample, the higher the likelihood of spread, and once Gleason grade 5 cells are present, the likelihood is very high.
So, it’s now obvious (and has been since at least 2002) why high-risk PC cases are not good candidates for surgery as primary treatment…it is to minimize the patient morbidity and retain as much QoL as possible. While the hypothetical surgery case described above found spread after
opening up the patient, high-risk cases are highly likely to have spread (typically NOT visible)...why go in to look when you already know of the high likelihood. There are a very small set of unique exceptions—halbert has already mentioned “de-bulking” which may be appropriate once one’s prostate blows up to softball size or greater and starts to interfere with other bodily functions in the slim minority of cases where finasteride is unable to be administered to shrink the prostate.
The history lesson is that back 70s and 80s and early 90s, after the radical prostatectomy was "refined" the norm was to just yank the prostates out of all PC patients first—that was truly the origins of the “one-size-fits-all” PC mantra. But for 20-some years now, the NCCN has helped discriminate between cases, and since that time, radiation as primary
treatment is been king for cases labeled high-risk at diagnosis. Surgery has also been an option, but not a good option.
Post Edited (NKinney) : 5/29/2018 9:18:47 AM (GMT-6)