INTERMEDIATE-RISKPROSTATE CANCERROLE OF SURGERY

KARIM TOUIJER, MD, MPH

ATTENDING SURGEON

MEMORIAL SLOAN KETTERING CANCER CENTER

INTERMEDIATERISKPROSTATE CANCER

HETEROGENEOUS GROUP

FAVORABLE INTERMEDIATE RISK

UNFAVORABLE INTERMEDIATE RISK

Zumzteg et al. BJU Int 2017 (120)

FAVORABLE INTERMEDIATERISK

ACTIVE SURVEILLANCE ?

FOCAL THERAPY ?

ACTIVE SURVEILLANCEFOR INTERMEDIATE-RISK CAP

Carlsson et al. AUA abstract 2018Cooperberg JCO 2011, 29(2)

TOTAL LENGTH OF GLEASON PATTERN 4ON BIOPSY

Dean et al. J Urol 2019 Jan 201

UNFAVORABLE INTERMEDIATERISK

SURGERY ?

RADIATION THERAPY + ADT

RANDOMIZEDCLINICALTRIAL PROTECT

Hamdy et al NEJM 2016;375

A

RANDOMIZED CLINICAL TRIAL:PROTECT

LARGELY LOW-RISK POPULATION

CANCER SPECIFIC MORTALITY : NO DIFFERENCE

METASTATIC PROGRESSION: NO DIFFERENCE

Hamdy F et al. N Engl J Med 2016; 375:1415-

OBSERVATIONAL STUDIES

MORE THAN 10 STUDIES IN THE PAST 10 YEARS

ACADEMIC, COMMUNITY, POPULATION BASED

TWOFOLD RISK ADJUSTED SURVIVAL ADVANTAGE OF RP OVER EBRT

Tewari A, et al. J Urol 2007;177 Albertsen PC et al. J Urol 2007;177. Zelefsky MJ, et al. J Clin Oncol 2010;28 Cooperberg MR. Cancer 2010;116 Stattin P, et al. J Natl Cancer Inst 2010;102 Boorjian SA, et al. Cancer 2011;117 Kibel A, et al.J Urol 2012;187. Hoffman RM, et al. J Natl Cancer Inst 2013;105Sun M, et al. BJU Int 2014;113. Sooriakumaran P, et al. BMJ 2014;348.

OBSERVATIONAL STUDIES

STUDY YEAR SITE DATA CONCLUSIONS

Tewari et al. 2007 Henry ford CSM HR 0.5 (0.3-1.0) favoring RP over EBRTAlbertsen et al. 2007 CT registry CSM RR 2.5 (1.7-3.5) favoring RP over EBRTZelefsky et al. 2010 MSKCC CSM HR 2.2 (1.3-7.7) favoring RP over EBRTCooperberg et al. 2010 CaPSURE CSM HR 2.2 (1.5-3.2) favoring RP over EBRTStattin el al. 2010 NPCR CSM HR 1.4 (0.9-2.0) favoring RP over EBRTBoorjian et al. 2011 Mayo/FC CSM HR 1.1 (0.7-1.9) NS. For RP vs. EBRTKibel et al. 2012 WashU/CCF CSM HR 1.5 (1.0-2.3) favoring RP over EBRTHoffman et al. 2013 PCOS CSM HR 2.9 (2.0-3.8) favoring RP over EBRTSun et al. 2014 SEER CSM HR 2.5 (1.5 – 4.2) favoring RP over EBRTSooriakumaran et al.

2014 PCBase CSM HR 1.8 (1.5-2.0) favoring RP over EBRT

Tewari A, et al. J Urol 2007;177 Albertsen PC et al. J Urol 2007;177. Zelefsky MJ, et al. J Clin Oncol 2010;28 Cooperberg MR. Cancer 2010;116 Stattin P, et al. J Natl Cancer Inst 2010;102 Boorjian SA, et al. Cancer 2011;117 Kibel A, et al.J Urol 2012;187. Hoffman RM, et al. J Natl Cancer Inst 2013;105Sun M, et al. BJU Int 2014;113. Sooriakumaran P, et al. BMJ 2014;348.

Zelefsky MJ, et al. J Clin Oncol 2010;28

Berlin j et al. J Urol; 2019 (feb) 201.

Berlin j et al. J Urol; 2019 (feb) 201.

QOL

Donovan et al . NEJM 2016 , 375

QOL

Donovan et al . NEJM 2016 , 375

QOL

Donovan et al . NEJM 2016 , 375

QOL

Donovan et al . NEJM 2016 , 375

QOL

Donovan et al . NEJM 2016 , 375

CONCLUSIONS

NO LEVEL I EVIDENCE

ONCOLOGICAL OUTCOMES FAVOR SURGERY

QOL DATA FAVOR RADIATION THERAPY THOUGH BOWEL TOXICITY IS WORSE WITH RT