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The bottom line, based on studies of hundreds of men who have had this procedure, is that radical prostatectomy cures the vast majority of men with cancer confined, to the prostate. It also cures most men even if cancer has reached or penetrated the prostate wall, if—and this is a big if—two crucial conditions are met: If the tumor cells are pretty well differentiated (a Gleason score of 6 or lower), and if surgeons are able to cut out all the cancer. In surgical terms, this is called getting a “clear surgical margin.” On the other hand, when a high-grade tumor has penetrated the prostate wall, or when the cancer has reached the seminal vesicles, the chances for a cure are not as certain.

One long-term study at Johns Hopkins, of 955 men with clinical stage Ti and T2 (A and B) cancer, found these results ten years after surgery: Only 4 percent had local recurrence of cancer, and 7 percent had distant metastases. And, using the PSA test, which is a highly sensitive measure for cancer recurrence, they found that 70 percent of the patients were cancer-free at ten years.

This study underlined the importance of the pathologic stage (the extent of cancer, determined at the time of surgery. At 10 years, the odds of being cancer-free, as measured by PSA levels, were 85 percent for men with disease confined to the prostate or who had very limited “capsular penetration,” or cancer that has just barely penetrated the prostate wall.

At eight years after surgery, all patients with capsular penetration but “negative surgical margins”—this means the doctors were able to cut out all the cancer—and a Gleason score of 6 or less had an undetectable PSA. Fifty percent of men with capsular penetration and “positive surgical margins”— which means the surgeon’s ability to cut out all the cancer is uncertain—and a Gleason score of 6 or less had an undetectable PSA at eight years. So did 50 percent of men with capsular penetration, negative surgical margins and a Gleason score of 7 or higher. And 25 percent of men with capsular penetration, positive surgical margins and a Gleason score of 7 or higher had an undetectable PSA eight years after surgery. (For more on positive surgical margins, see “Radiation after Prostatectomy,” in Chapter 6.)

Some of the men who had an elevated PSA score went ahead and had radiation treatment; in 10 percent of these men, the radiation seemed to work—PSA plummeted to the undetectable range and stayed there for at least two years.

Why doesn’t radical prostatectomy cure every man? Because the cancer has escaped the prostate before surgery, either locally, to the point where surgeons can’t remove it all, or through impossible-to-detect, distant metastases. This is why many urologists make such a painstaking effort to figure out the exact stage of a man’s cancer before surgery. They believe it’s important to operate only on the patients who are going to benefit most and have the greatest long-term survival.

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Better understanding of the anatomical terrain also led to another important bonus: Surgeons now knew exactly where the scalpel could and could not go. So, depending on the extent of a man’s cancer, it became possible for them either to save these nerves deliberately, or to remove more tissue by cutting these bundles away—in surgical terms, to create “wider margins of excision”— than they previously had believed possible. (Before this discovery, surgeons routinely gave this area a wider berth because they were afraid of injuring the patient’s rectum.) Which means that with these anatomical techniques, surgeons now have a better chance of removing all the cancer.

Today at Johns Hopkins (the hospital is noted here because results vary worldwide, depending on a range of factors including the surgeon’s skill and the selection criteria for patients), in men aged 50 to 59 who undergo anatomical radical retropubic prostatectomy, 75 percent regain potency. (Overall, at ten years or more after surgery, only 4 percent have local recurrence of cancer, and only 7 percent develop distant metastases; and 70 percent have an undetectable level of PSA.) Important determinants in the return of sexual function include age, the stage of cancer, and the extent of nerve loss—whether one or both nerve bundles remain, or whether they had to be removed during surgery.

We used to say, “If we make a diagnosis and you’re going to need surgery, it may make you incontinent and impotent.” And patients said, “Hold the phone! I’d rather have the disease.” Now, when we talk to patients, we tell them we have three goals: Removing all of the tumor, preserving urinary control, and preserving sexual function. Sexual function is number three because, if it is lost, there are many ways to restore it.

Men who are impotent following radical prostatectomy have normal sensation, normal sex drive, and can achieve a normal orgasm. The one element they may be lacking is the ability to have an erection sufficient for intercourse, and that can be restored by means including a vacuum erection device, injections, even a penile prosthesis.

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Although some men appear to have clinically localized cancer, there’s a good chance that their cancer has spread beyond the prostate (see table 3.3).

For these men, the combination of radiation and surgery might sound like a promising option. However, it is not yet certain whether radiation after prostatectomy is ultimately helpful. Note: Radical prostatectomy is definitely not very successful in men who have undergone radiation treatment, and in the minds of many urologists, surgery after the fact is not an option. However, men who have undergone radical prostatectomy can go ahead and have radiation therapy later.

Some surgeons recommend hormonal treatment to shrink the prostate (and, they hope, the tumor) before radical prostatectomy, believing that this will make the cancer more curable. But, as one Johns Hopkins scientist explains, “hormone therapy is not a vacuum cleaner—it can’t suck the cancer cells back into the prostate once they’ve escaped.” There is no reason to believe that hormone treatment before radical prostatectomy will make it possible for surgeons to retrieve and eliminate cancer cells that have strayed from the prostate. Also, this approach may mislead a surgeon into thinking the cancer picture is rosier than it actually is, and thereby encourage a less-aggressive cancer operation.

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When 5 percent or less of the tissue was cancerous, only 17 percent of the men went on to develop more advanced cancer; this is now the classification for stage T1a, or A1, disease. But when more than 5 percent of the resected tissue was cancerous, 68 percent of these men went on to develop cancer progression; this now is the classification of stage T1a, or A2, disease. “It is felt that the amount of cancer in almost all of these patients is significant enough to warrant therapy,” says one of the investigators.

Further analysis has shown that when men with stage T1a disease undergo radical prostatectomy, about 25 percent of them turn out to have a significant amount of cancer in the prostate—the kind of cancer that’s found in men with palpable tumors.

So: Some men with stage T1a cancer require treatment. Some don’t. How to tell the difference? Our old friend PSA comes back to help us again. As it turns out, the level of PSA three months after TUR can be helpful in identifying the men at highest risk of cancer progression. If the PSA is less than 1.o, virtually all of the men with stage T1a (A1) disease have an insignificant amount of cancer. “And we feel that these men can probably be followed with careful digital rectal examinations and PSA tests every six months or a year,” says one of the study’s chief investigators.

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Prostate cancer grows relatively slowly. When it is localized, it takes two or three years to double in size. And the confounding fact is that cancer can stay in the prostate indefinitely. It takes a long time and many steps involving subde genetic changes before a normal cell, which is designed to live and die, becomes a cancer cell—before some switch is activated that makes the cell think it’s immortal—and before such cells start dividing endlessly. (In high-risk men, some of these steps may be shortened.

If localized prostate cancer is found in a 65-year-old man, for example, it could stay localized for years and he may die with prostate cancer, not of it. This is what happens to hundreds of thousands of men, and it’s one of the factors that can make treatment decisions so cloudy.

But—and this is the crux of the issue—once it escapes the prostate, cancer’s growth is relentless. It can no longer be cured. Once the cancer has spread to bone, the average life expectancy for a man is about three years.

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