If a man is diagnosed with locally advanced prostate cancer he has high-risk prostate cancer. Locally advanced refers to tumours that have pushed outside of the prostate gland to nearby regions. Men with this stage of prostate cancer have a number of treatment options to give them the best chance of surviving this disease. A recent clinical trial has compared the success and side effects of different treatments for locally advanced prostate cancer.
Different types of advanced prostate cancer
For some men, their cancer is not detected until it has spread beyond the prostate gland. This stage is referred to as advanced prostate cancer. Men with advanced prostate cancer either have locally advanced disease or metastatic disease.
Locally advanced prostate cancer has spread outside the prostate region but is not detected at distant sites. Stage T3 refers to prostate cancer that has spread to nearby regions such as the seminal vesicles. Stage T4 sees the tumour spread further, to nearby organs such as the bladder or rectum (back passage).
Metastatic prostate cancer, on the other hand, is a term used to described tumours that have spread to distant regions such as the bones, liver or lungs. Some men are told that they have local metastases (or regionally advanced prostate cancer). This refers to tumours that have spread to lymph nodes close to the prostate.
Diagnosis of locally advanced prostate cancer is not always straightforward. PSA levels and biopsies prior to treatment can’t accurately determine whether a tumour has spread out of the prostate. MRI scans and pelvic CT scans can sometimes show if a prostate cancer is locally advanced. Often men will find out that they have locally advanced disease after surgery. They are told that they have a positive surgical margin, which indicates that the cancer may have spread further than the prostate gland. Rising PSA levels soon after surgery can be a sign of locally advanced prostate cancer.
Treatments for locally advanced prostate cancer
Men with locally advanced prostate cancer have high-risk disease. Locally advanced actually refers to prostate cancers that vary widely. The age, health and treatment preferences of the men who have this disease also vary. Doctors therefore recommend various different therapies for these men, trying to best treat their cancer whilst avoiding nasty side effects. Often the treatment involves more than one approach. Common options for men with locally advanced prostate cancer are surgery, radiotherapy and hormone therapy (androgen deprivation therapy (ADT)).
Surgery to remove the prostate for men with locally advanced disease has traditionally been discouraged in the past. As a surgery, it’s considered technically challenging, and many of these cancers spread despite the surgery. But results from subsequent clinical trials have shown that surgery followed by radiotherapy can help these men to live for longer.
What is the best treatment for locally advanced prostate cancer?
Results have recently been published from an observational study that aimed to compare different treatment regimens for locally advanced prostate cancer. The researchers behind this study are an American team based at The Rutgers Cancer Institute of New Jersey. They were led by Dr Thomas Jang, a urologic oncologist. The results of this study have been published in the journal Cancer.
The New Jersey study looked at historical records from American patients using SEER data. SEER stands for Surveillance, Epidemiology and End Results. These data records tell us much about prostate cancer treatments and survival rates in the USA over the past decades. They can be found at this National Institutes of Health website.
For this study, records were accessed from patients diagnosed with locally advanced prostate cancer or regionally advanced prostate cancer. The term regionally advanced was used to described prostate cancers that had spread out of the prostate and to one lymph node in the pelvic region. 13,856 men were diagnosed with locally or regionally advanced prostate cancer in the USA between 1992 and 2009. These men were all 65 years of age or older. The treatments received by these men were:
- 20.8% (2884 men) had prostate surgery only
- 18.3% (2541 men) had radiotherapy only
- 11.2% (1545 men) had ADT only
- 6.1% (848 men) had surgery plus radiotherapy (253 of these men also had ADT)
- 23.6% (3272 men) had radiotherapy plus ADT
- 20% (2766 men) of men had no treatment in the 6 months after diagnosis
The main aim of this study was to compare the success and the side effects of the combined treatments – these are surgery plus radiotherapy, compared to radiotherapy plus ADT.
Looking at the patient records, the researchers found that there were differences between the men choosing different treatment options. Men with other serious health issues, men who were unmarried and those diagnosed more recently were more likely to receive radiotherapy with ADT, than surgery with radiotherapy. The proportion of men receiving surgery plus radiotherapy in the USA has decreased over time. The researchers also found that men who had a lymph node tumour (regional advanced disease) were more likely to have surgery plus radiotherapy.
The average length of follow-up time was 14.6 years. During this time, 2,189 out of the 13,856 men had died. But only 702 of the men died from prostate cancer. During their analysis, the researchers were able to adjust for the differences between the groups of men (such as being older or diagnosed more recently). After these adjustments, the data showed that men having surgery plus radiotherapy were at lower risk of dying than men having radiotherapy with ADT.
For men with locally advanced prostate cancer at stage T3, 64.2% were alive 10 years after diagnosis if they had surgery and radiotherapy. But for those who had radiotherapy plus ADT, only 48.3% of men survived for 10 years.
The survival rate was lower for men who had locally advanced prostate cancer at the T4 stage. 49.6% survived for at least 10 years if they had surgery and radiotherapy, but only 34.9 survival for 10 years if they had radiotherapy and ADT.
It needs to be noted that these survival rates come from medical records going back to 1992. New radiotherapy technologies, ADT drugs and surgical techniques are now being used. Prostate cancer survival rates in the USA and in Australia are higher that they were at the time that many of these men were being treated for prostate cancer. So these percentages are not necessarily relevant for today.
Side effects from treatment for locally advanced prostate cancer
Men with locally advanced prostate cancer who had surgery and radiotherapy lived for longer, but unfortunately this came with a higher rate of side effects.
Urinary incontinence: 49.1% of the men having surgery plus radiotherapy suffered urinary incontinence, compared to 19.4% of men having radiotherapy plus ADT.
Erections problems: 28.8% of men have surgery plus radiotherapy had erection problems compared to 20.4% of men having radiotherapy plus ADT. This was calculated using Medicare claims information (from the USA’s Medicare system). These percentages were men claiming costs of medicines or treatments for treating erection problems. Surveys asking the men if they had problems at the time would have been more accurate, but this cannot easily be done so far in the future.
Men having surgery plus radiotherapy were also more likely to need further treatment to address bladder problems.
The researchers compared rates of many other issues such as osteoporosis, heart conditions, bone fractures and rectal bleeding. There were no differences between rates of these complications between men in the two different treatment groups.
Limitations of this study
The New Jersey study was an observational study, not a randomised controlled trial. So there are some limitations that mean we are not as sure of the results as we would like to be.
The groups of men choosing different treatment options were different. The researchers were able to adjust for various differences that they measured. But there may have been other differences that weren’t measured. Unknown differences between the two groups may have affected these men’s survival rates and chances of experiencing side effects.
Another issue is that much of the data in the study came from Medicare claim information. There may be key information that influenced the survival rates and side effects that was not able to be found in the Medicare claim records.
Lastly, the study needed to cover a long period of time in order to assess survival rates. Patient records were accessed from as far back as 1992. New ADT drugs are available and technologies for radiotherapy and surgical have improved greatly in that time, so survival rates are higher today.
What does this mean for men with prostate cancer?
This study of historical Medicare records from the USA indicated that men with locally advanced prostate cancer had a long survival time if they were treated with surgery plus radiotherapy, rather than radiotherapy plus ADT. But the trade-off was that the men having surgery plus radiotherapy had a higher chance of problematic side effects. This observational study is well-regarded. But as it’s not a randomised controlled trial, there are some limitations that mean we are not as sure of the results as we’d like to be.
There are numerous different treatment options for men with locally advanced prostate cancer. The best treatment for each man depends on many different issues. PCFA recommends a discussion of these options with specialists such as urologists, radiation oncologists and medical oncologists to help decide which is the most appropriate treatment pathway. Getting a second opinion is a good idea if you are unsure of the best way forward. We have information to help men with advanced prostate cancer available at this link or by calling 1800 22 00 99.
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