Progresión metastática, mortalidad cáncer específica y necesidad de tratamientos de segunda línea en pacientes con cáncer de próstata de alto riesgo tratados inicialmente mediante prostatectomía radical

Multicenter study on multidisciplinary committees in advanced prostate cancer

INTRODUCTION AND OBJECTIVE

Although Multidisciplinary Teams (MDTs) are recommended in the management of Advanced Prostate Cancer (APC), their functioning in real practice has been poorly evaluated. We carried out a multicenter study with the objective of evaluating the functioning of uro-oncology MDTs in 6 hospitals.

MATERIALS AND METHODS

A descriptive cross-sectional study was performed. The level of Compliance with the Fundamental Quality Requirements (CFQR) of the MDTs was evaluated by means of a questionnaire filled out by the coordinators of the MDTs in each hospital. The information on the perspective of the members of the MDTs was evaluated through an anonymous survey.

RESULTS

A high level of CFQR in MDTs was evidenced (75%), showing deficiencies in terms of protocol update, agendas, audits, and scientific production. The survey was answered by 62.32% of the 69 physicians surveyed (urologists, oncologists, radiation therapists, radiologists, and pathologists). The 88.4% consider the duration of the meetings appropriate. There are disparate opinions concerning the protection of the MDT meeting time as well as protocol update. Of the patients with APC presented at the MDTs meeting, 62,8% require intervention from two specialties. Only 50% of respondents believe that all CRPC cases are discussed and that there is a prior agenda. The decisions made by the MDTs are reflected in the clinical history in 65.1% and are binding only in 60.5% of the cases. Half of the respondents have not been trained in MDTs. Most participants (90.7%) agree on the fact that MDTs. convey benefits.

CONCLUSIONS

The evaluations of the MDTs identify rectifiable deficiencies by modifying hospital inertia and care planning.

Long-term oncological results of treatment for high-risk prostate cancer using radical prostatectomy in a cancer hospital

OBJECTIVES

To analyse the most relevant oncologic results of treatment using radical prostatectomy (RP) for high-risk prostate cancer (HRPC) in a specialist cancer hospital.

MATERIAL AND METHODS

A descriptive retrospective study of RP was conducted at our centre from 1986 to 2017 on HRPC whose primary objective was to determine overall survival (OS) and cancer-specific survival (CSS). The study's secondary objectives were to determine biochemical progression-free survival (BPFS), metastasis-free survival (MFS), rescue therapy-free survival (RTFS), hormone therapy-free survival (HTFS) and the development of castration-resistant prostate cancer. We performed a Cox regression analysis to establish predictive models and to better understand the weight of each variable that defines high risk.

RESULTS

A total of 2093 RPs were performed, 480 (22.9%) of which were for HRPC. The median follow-up for the overall series was 79.57 months (P_25-75 37.92-135.16). Lymphadenectomy was not performed in 6.5% of the cases. The lymphadenectomy was of the obturator type in 51.2% of the cases and extended in 42.3%. Overall survival at 5, 10 and 15 years was 89.8% (95% CI 86.7-92.9%), 73.3% (95% CI 68-78.6%) and 51.4% (95% CI 43.8-59%), respectively. CSS at 5, 10 and 15 years was 94.8% (95% CI 92.4-97.2%), 84.0% (95% CI 79.3-88.7%) and 75.5% (95% CI 68.8-82.2%), respectively. MFS at 5, 10 and 15 years was 87.4% (95% CI 84.1-90.7%), 72.2% (95% CI 66.7-77.7%) and 61.7% (95% CI 54.3-69.1%), respectively. A total of 120 patients of 477 analysed (25.1%) required rescue radiation therapy, and 293/477 never required hormone therapy (61.4%). Of the 93 pN1 patients, 33 (35.5%) did not require hormone therapy. The time from RP to biochemical progression was the variable with the greatest prognostic weight for MFS, CSS and overall survival.

CONCLUSIONS

RP plus extended lymphadenectomy should be the first therapeutic manoeuvre when feasible within a multimodal strategy. A longer follow-up of the series is needed to validate the hypothesis of better oncologic results based on the earlier implementation of rescue radiation therapy, extended lymphadenectomy and drugs that prolong survival in the CRPC phase.

The role of radical prostatectomy as an initial approach for the treatment of high-risk prostate cancer

CONTEXT

The treatment of high-risk prostate cancer requires a multimodal approach to improve control of the disease. There is still no consensus as to the initial strategy of choice. The aim of this study is to review the results of radical prostatectomy as first step in management of patients with high-risk disease.

ACQUISITION OF EVIDENCE

A search was conducted on PubMed of English and Spanish texts. We included those studies that reported the results of radical prostatectomy in patients with high-risk prostate cancer, as well as those that compared radical prostatectomy with other treatment alternatives. The last search was conducted in November 2015.

SYNTHESIS OF THE EVIDENCE

The advantages of radical prostatectomy include a better pathological analysis, more accurate staging, better local control of the disease and better follow-up and adjuvant therapy strategies. When compared with external radiation therapy plus hormonal blockade, the patients who underwent prostatectomy had greater chances of healing and longer cancer-specific survival. The patients who most benefit from this approach are younger, have fewer comorbidities and no evidence of organ metastases.

CONCLUSIONS

The available scientific evidence to date is not without bias and confounders; however, they appear to favour radical prostatectomy as the initial approach of choice for high-risk prostate cancer.

External validation of nomogram predicting the probability of specimen-confined disease (pT2-3a, R0N0) in patients undergoing radical prostatectomy and pelvic lymph node dissection

INTRODUCTION

Before radical prostatectomy (RP), a nomogram [Briganti et al., Eur Urol 2012;61:584-592] permits to measure the probability of specimen-confined (SC) disease (pT2-pT3a, node negative with negative margins) in high-risk prostate cancer (PCa). The aim of our study was to perform an external validation of this nomogram.

MATERIALS AND METHODS

Between 2007 and 2011, 623 patients with high-risk PCa (prostate-specific antigen (PSA) >20 ng/ml and/or biopsy Gleason score ≥8 and/or clinical stage T3) underwent RP and pelvic lymph node dissection at tertiary referral centers. Multivariable logistic regression models predicting the presence of SC disease were built in; we then used the area under curve of the receiver operating characteristic analysis to quantify accuracy of the nomogram to predict SC disease. The extent of over- or underestimation was evaluated within calibration plots.

RESULTS

29% (181/623) of men had SC disease at RP. Preoperative PSA, biopsy Gleason score and stage differed significantly (all p < 0.001) between men with SC disease and those without. External validation of the nomogram showed an acceptable accuracy (area under curve: 66.3, 95% CI 62.4-70%) and a perfect calibration plot.

CONCLUSIONS

The external cohort validates the original nomogram, with perfect calibration characteristics. The adequate although reduced accuracy may reflect the wide spectrum and behavior of the so-called high-risk PCa.