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Article of the week: Men under 50 should not be discouraged from radical prostatectomy

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Andreas Becker discussing his paper.

If you only have time to read one article this week, it should be this one.

Functional and oncological outcomes of patients aged <50 years treated with radical prostatectomy for localised prostate cancer in a European population

Andreas Becker*, Pierre Tennstedt*, Jens Hansen*, Quoc-Dien Trinh, Luis Kluth, Nabil Atassi*, Thorsten Schlomm*, Georg Salomon*, Alexander Haese*, Lars Budaeus*, Uwe Michl*, Hans Heinzer*, Hartwig Huland*, Markus Graefen* and Thomas Steuber*

*Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany, Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada, andDepartment of Urology, University-Hospital Hamburg-Eppendorf, Hamburg, Germany

OBJECTIVE

• To address the biochemical and functional outcomes after radical prostatectomy (RP) of men aged <50 years in a large European population.

PATIENTS AND METHODS

• Among 13 268 patients who underwent RP for clinically localised prostate cancer at our centre (1992–2011), 443 (3.3%) men aged <50 were identified.

• Biochemical recurrence (BCR) and functional outcomes (International Index of Erectile Function [IIEF-5], use of pads), were prospectively evaluated and compared between men aged <50 years and older patients.

RESULTS

• Men aged <50 years were more likely to harbour D’Amico low-risk (49.4 vs 34.9%, P < 0.001), organ-confined (82.6 vs 69.4%, P < 0.001) and low-grade tumours (Gleason score <7: 33.1 vs 28.7%, P < 0.001).

• Multivariate Cox regression analysis showed that age <50 years (hazard ratio 0.99; confidence interval 0.72–1.31; P = 0.9) was not a predictor of BCR.

• Urinary continence was more favourable in younger patients, resulting in continence rates of 97.4% vs 91.6% in most recent years (2009–2011) for patients aged <50 vs ≥50 years.

• After RP, a median IIEF-5 drop of 4 points in younger men vs 8 points in older patients was recorded (P < 0.001).

• Favourable recovery of urinary continence and erectile function in patients aged <50 years compared with their older counterparts was confirmed after multivariable adjustment.

CONCLUSION

• Men aged <50 years diagnosed with localised prostate cancer should not be discouraged from RP, as the postoperative rates of urinary incontinence and erectile dysfunction are low and probability of BCR-free survival at 2 and 5 years is high.

 

Editorial: Radical prostatectomy at young age

Becker et al. [1] investigated a large sample of young patients (aged <50 years) who underwent radical prostatectomy during a 20-year period in a high-volume European centre. In this study [1], men aged <50 years had a significantly more favourable functional outcome (continence rates [0–1 pads] 97% vs 92%; International Index of Erectile Function [IIEF] score drop of 4 vs 8 points), compared with their older counterparts. Biochemical tumour control was higher in younger patients in univariate (5-year rates 81% vs 70%) but not in multivariate analysis.

In studies in the pre-PSA era, young age at prostate cancer diagnosis was often associated with adverse tumour-related outcome [2]. Possibly, the disadvantage of younger patients was attributable to rapidly growing high-grade tumours causing symptoms at a young age in the absence of a dilution by favourable early detected low-grade cancers. In contemporary patients, the opposite is observed [1]. As the impact of age vanished after controlling for tumour-related prognostic factors reflecting the presence of more favourable disease criteria in younger men, it may be considered likely that PSA-based early detection enriched favourable parameters in the younger subgroup. Altogether, prostate cancer biology is probably not meaningfully associated with age. Outcome differences, even in randomised trials [3, 4], are rather caused by age-related differences in the approach to prostate cancer diagnostics and early detection than in actual biological differences.

The relative favourable functional outcome in younger patients [1] supports early curative treatment in this population. Currently available active surveillance studies have very limited follow-up and were performed mainly in elderly patients with significant comorbidity [5]. Currently, in Germany the further life expectancy in men aged 50 years is ≈30 years [6]. In a contemporary active surveillance study, narrowly half of patients received active treatment within 10 years [5]. Therefore, most men starting active surveillance at an age of 50 years will subsequently receive active treatment. This treatment will then be performed at a greater age where the chances for satisfactory functional recovery are less favourable.

The inferior tumour control rates in patients receiving robot-assisted surgery is another remarkable finding of this study (hazard ratio 1.4, 95% CI 0.99–1.9, P = 0.06 in the multivariate analysis). Although the significance level was narrowly failed, this observation cannot be ignored. It was accompanied by an increased continence recovery rate after robot-assisted surgery suggesting that it may probably not be attributed to the learning curve. Less radical removal of the prostate with more sparing of neurovascular structures and bladder neck might be a conceivable explanation of this phenomenon. In this study [1], the prognostic impact of robot-assisted approach was in a similar range as a positive surgical margin (hazard ratio 1.5, 95% CI 1.4–1.7).

Current clinical guidelines discourage prostate cancer screening in average-risk men aged <50 years [7]. It remains to be seen in which degree these recommendations will affect clinical practice and outcome parameters in this age group in the years ahead.

Manfred P. Wirth and Michael Froehner
Department of Urology, University Hospital ‘Carl Gustav Carus’, Dresden University of Technology, Dresden, Germany

References

  1. Becker A, Tennstedt P, Hansen J et al. Functional and oncological outcomes of patients younger than 50 years treated with radical prostatectomy for localized prostate cancer in a European population. BJU Int 2014; 114: 38–45
  2. Parker CC, Gospodarowicz M, Warde P. Does age influence the behaviour of localized prostate cancer? BJU Int 2001; 87: 629–637
  3. Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2011; 364: 1708–1717
  4. Froehner M, Wirth MP. Early prostate cancer – treat or watch? N Engl J Med 2011; 365: 568
  5. Selvadurai ED, Singhera M, Thomas K et al. Medium-term outcomes of active surveillance for localised prostate cancer. Eur Urol 2013; 64: 981–987
  6. Statistisches Bundesamt. Periodensterbetafeln für Deutschland 1871/1881 bis 2008/2010 [Period death tables for Germany 1871/1881 bis 2008/2010]. Wiesbaden 2012. Available at: https://www.destatis.de/DE/Publikationen/Thematisch/Bevoelkerung/Bevoelkerungsbewegung/PeriodensterbetafelnPDF_5126202.pdf?__blob=publicationFile [Website in German]. Accessed 12 July 2013.
  7. Qaseem A, Barry MJ, Denberg TD, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2013; 158: 761–769

Video: RP for younger men – low risk and high survival rate

Functional and oncological outcomes of patients aged <50 years treated with radical prostatectomy for localised prostate cancer in a European population

Andreas Becker*, Pierre Tennstedt*, Jens Hansen*, Quoc-Dien Trinh, Luis Kluth, Nabil Atassi*, Thorsten Schlomm*, Georg Salomon*, Alexander Haese*, Lars Budaeus*, Uwe Michl*, Hans Heinzer*, Hartwig Huland*, Markus Graefen* and Thomas Steuber*

*Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany, Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada, andDepartment of Urology, University-Hospital Hamburg-Eppendorf, Hamburg, Germany

OBJECTIVE

• To address the biochemical and functional outcomes after radical prostatectomy (RP) of men aged <50 years in a large European population.

PATIENTS AND METHODS

• Among 13 268 patients who underwent RP for clinically localised prostate cancer at our centre (1992–2011), 443 (3.3%) men aged <50 were identified.

• Biochemical recurrence (BCR) and functional outcomes (International Index of Erectile Function [IIEF-5], use of pads), were prospectively evaluated and compared between men aged <50 years and older patients.

RESULTS

• Men aged <50 years were more likely to harbour D’Amico low-risk (49.4 vs 34.9%, P < 0.001), organ-confined (82.6 vs 69.4%, P < 0.001) and low-grade tumours (Gleason score <7: 33.1 vs 28.7%, P < 0.001).

• Multivariate Cox regression analysis showed that age <50 years (hazard ratio 0.99; confidence interval 0.72–1.31; P = 0.9) was not a predictor of BCR.

• Urinary continence was more favourable in younger patients, resulting in continence rates of 97.4% vs 91.6% in most recent years (2009–2011) for patients aged <50 vs ≥50 years.

• After RP, a median IIEF-5 drop of 4 points in younger men vs 8 points in older patients was recorded (P < 0.001).

• Favourable recovery of urinary continence and erectile function in patients aged <50 years compared with their older counterparts was confirmed after multivariable adjustment.

CONCLUSION

• Men aged <50 years diagnosed with localised prostate cancer should not be discouraged from RP, as the postoperative rates of urinary incontinence and erectile dysfunction are low and probability of BCR-free survival at 2 and 5 years is high.

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