Radical prostatectomy at young age

Abstract

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. M.W. received payment for lectures on behalf of Novartis, GlaxoSmithKline and Pfizer and received travel/accommodation/meeting expenses for Janssen and Pfizer outside the submitted work. M.F. is a consultant for Bayer Vital, Dendreon, Janssen, Merck, Myriad Service, Takeda Oncology Company – Millennium Pharmaceuticals and received payment for expert testimony from Farco-Pharma, Apogepha Arzneimittel and lectures on behalf of Pfizer, Orion Pharma, Sanofi-Aventis Deutschland, Solution akademie, all outside the submitted work.