by David Y. Josephson, MD, FACS
Cytoreductive surgery or the removal of the primary organ in the setting of metastatic disease is a debulking type of treatment that is used to enhance the effectiveness of systemic therapies. It has been shown to have favorable impact on survival and the use of systemic therapies in ovarian, brain and kidney cancer. Cytoreductive radical prostatectomy or performing prostate removal in the setting of metastatic disease has not gained widespread acceptance in the past because it was always felt not to have a significant impact on local progression of prostate cancer or overall survival. However the significant preventative effects of this approach has recently been re-evaluated and reflected by number of published studies.
A recent analysis (Won BJU Int 2013; 112) evaluating the outcomes of over 200 patients with hormone resistant prostate cancer who underwent either surgery, radiation, or no local treatment before instituting androgen deprivation showed significant reduction in local complications including bladder outlet obstruction, hematuria, and additional surgical interventions for those patients who underwent a prophylactic prostatectomy. Opponents of this approach in the past quoted increased amounts of surgical related complications and the lack of effect on overall survival. A more recent feasibility study from Aachen, Germany published in the Journal of Urology (Heidenreich J Urology 2015; 193, p 832) has had shed further light to the beneficial effects of this multimodal approach. They analyzed a small group of patients with biopsy-proven high-risk prostate cancer with minimal amounts of bony metastasis (3 spots or less) who had good response to starting hormone therapy with a PSA response to less than 1. An additional group with metastatic prostate cancer who were treated with hormonal therapy alone without surgery serves as a control group. With a median followup of approximately 3 years, the median time to becoming castrate resistant increased by 11 months, clinical progression free survival increased by one year, and cancer specific survival rates were improved by 12%.
Due to the recent bad press and controversy surrounding the utility of PSA as a screening test, we have begun seeing many more patients presenting with higher risk and/or metastatic prostate cancer. I believe we will soon many more studies like the above showing the feasibility and safety of cytoreductive prostatectomy with further evidence of improving both overall and cancer specific survival.