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Table 39 8 CAPRA: Probability of freedom from PSA recurrence after radical prostatectomy by CAPRA point total
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3-year recurrence free survival (%)(95% CI) 91 (85 95) 89 (83 94) 81 (73 87) 81 (69 89) 69 (51 82) 54 (27 75) 24 (9 43) 5-year recurrence free survival (%) (95% CI) 85 (73 92) 81 (69 89) 66 (54 76) 59 (40 74) 60 (37 77) 34 (12 57) 8 (0 28)
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CAPRA score 0 1 2 3 4 5 6 7+
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PSA, prostate-specific antigen
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Treatment
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A Localized Disease
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What constitutes the optimal form of treatment for patients with clinically localized cancers remains controversial Treatment decisions are at present made on the basis of tumor grade and stage and the age and health of the patient
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Although selected patients may be candidates for surveillance based on age or health and the presence of small-volume or well-differentiated cancers, most patients with an anticipated survival in excess of 10 years should be considered for treatment Both radiation therapy and radical prostatectomy allow for acceptable levels of local control The first large, prospective, randomized trial of watchful waiting compared with radical prostatectomy has been reported Six hundred ninetyfive men were randomized and monitored for a median of 82 years Radical prostatectomy reduced disease-specific mortality, overall mortality, and risks of metastasis and local progression The absolute reduction in the risk of death after 10 years was small, but the reductions in the risks of metastasis and local tumor progression were substantial This trial accrued patients in Sweden between 1989 and 1999, so the patients enrolled likely had a greater burden of disease than is average for patients who are newly diagnosed in areas where PSA screening is common Patients need to be advised of all treatment options (including surveillance) along with the particular benefits, risks, and limitations
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Table 39 7 The UCSF Cancer of the Prostate Risk Assessment (CAPRA)
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Variable PSA (ng/mL) Level 0 6 61 10 101 20 201 30 > 30 1 3/1 3 1 3/4 5 4 5/1 5 T1 or T2 T3a < 34% > 34% < 50 years > 50 years Points 0 1 2 3 4 0 1 3 0 1 0 1 0 1
B Radical Prostatectomy
In radical prostatectomy, the seminal vesicles, prostate, and ampullae of the vas deferens are removed Refinements in technique have allowed maintenance of urinary continence in most patients and erectile function in selected patients Radical prostatectomy can be performed via open retropubic surgery, transperineally, or laparoscopically, with or without the assistance of surgical robotics Local recurrence is uncommon after radical prostatectomy, and its incidence is related to pathologic stage Organ-confined cancers rarely recur However, cancers found to be locally extensive (capsular penetration, seminal vesicle invasion) are associated with higher local (10 25%) and distant (20 50%) relapse rates Ideal candidates for the procedure include healthy patients with stages T1 and T2 prostate cancers Patients with advanced local tumors (T3 and T4) and those with lymph node metastases are rarely candidates for this procedure, although surgery is sometimes used in combination with hormonal therapy and postoperative radiation therapy for select high-risk patients
Gleason grade
T-stage % positive biopsies (biopsy cores positive divided by the number of biopsies obtained) Age
CMDT 2008
progress to clinical significance So, careful surveillance of low-risk patients with serial PSA levels, rectal examination, and periodic repeat prostate biopsies to assess grade and extent of tumor is reasonable The goal of surveillance is to recognize and treat patients with early evidence of progression effectively and to avoid treatment in patients who may never experience progression End points for intervention in patients on surveillance regimens have not been clearly defined and surveillance regimens remain investigational
Patients with advanced pathologic stage or positive surgical margins are at an increased risk for local and distant tumor relapse Such patients are often considered candidates for adjuvant therapy (radiation for positive margins or androgen deprivation for lymph node metastases) Although adjuvant radiation seems to be associated with fewer local recurrences (0 5% with radiation versus 15 30% without), it has little or no impact on distant failure rates (30 35% with radiation versus 30 45% without)
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