Men initially diagnosed with advanced prostate cancer often face a serious question, whether traditional primary treatments that would remove or make smaller their primary tumor (“debulking” the tumor) provide any advantage or extend their survival. Since the most commonly used method to debulk tumors is surgery or radiation the question becomes if the risks of these treatments still provide a man with a statistical advantage over skipping primary treatments.

In a paper by Culp et al. in European Urology there was some preliminary data to suggest that the debulking of the primary tumor may offer a positive long-term survival benefit in at least some men with metastatic disease at time of diagnosis.

Culp et al. used Surveillance Epidemiology and End Results (SEER) data for the period 2004 to 2010 for patients initially diagnosed with TxNxM1a–c disease (Stage IV). Culp divided the men into three study groups:

1- Men who received a radical prostatectomy with or without adjuvant external beam radiation therapy (the RP group)
2- Men who received brachytherapy with or without adjuvant external beam radiation therapy (the BT group)
3- Men who received no form of surgery or radiation therapy at all (the NSR group)

The study analyzed a large cohort of 8,185 men of who were separated into groups composed of:

1- 245 men were in the RP group.
2- 129 men were in the BT group.
3- 7,811 men were in the NSR group.

With an average (median) follow-up of 16 months they found that:
1- 3,115/8,185 patients (38.1 percent) died of prostate cancer.
2- 33/245 men (13.5 percent) were in the RP group.
3- 34/129 men (26.4 percent) were in the BT group.
4- 3,048/7,811 men (40.7 percent) were in the NSR group.

They projected that the 5-year overall survival was
1- 67.4 percent among men in the RP group
2- 52.6 percent among men in the BT group
3- 22.5 percent among men in the NSR group

The projected 5-year prostate cancer-specific survival was
4- 75.8 percent among men in the RP group
5- 61.3 percent among men in the BT group
6- 48.7 percent among men in the NSR group

Culp concluded that having primary treatment either a radical prostatectomy or having brachytherapy were both, associated with a lower risk for prostate cancer-specific mortality, or you could live longer.

Their results were similar regardless of the sub-stage of metastatic disease. They also found that the risk for prostate cancer-specific mortality among the men in the RP and the BT groups included

1- The presence of stage T4 disease
2- The presence of high-grade disease
3- A PSA level at diagnosis > 20 ng/ml
4- Age of 70 years of more
5- The presence of node-positive disease

Culp was very careful in the interpretation of the data, and so should we be, because there are a number of limitations of the data available from this analysis. For instance there is a lack of information in the SEER database about variables known to influence the survival of patients with metastatic prostate cancer (including treatment with systemic therapies).

Despite the limitations of the data we need to encourage men who have an initial diagnosis of advanced prostate cancer, especially node positive disease to have a serious conversation with their doctor about moving a head with a “primary” type of treatment, despite the fact that the disease has already left the gland.

Joel T Nowak, M.A., M.S.W.