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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