This content is part of a paid partnership with The Prostate Clinic.
Surgery is the only curative treatment for prostate cancer. If we can remove every last cancer cell, we achieve cure, proven by an undetectable PSA.
Consultant Urologist
A/Prof Shannon is a graduate of the University of WA. He completed his Fellowship in Urology in 1999 and completed post-fellowship training in the UK and the US focusing on minimally invasive surgery and prostate brachytherapy. He was a pioneer of minimally invasive urological surgery in WA and is a leader in the development of prostate MRI. He is a strong advocate for men’s health and has been a board member of the Prostate Cancer Foundation of Australia (WA) for over 10 years.
Life expectancy at diagnosis is now around 20 years and non-curative treatments may simply not last long enough. Subsequent lifelong ADT and chemotherapy are now known to be associated with significant complications and quality of life issues, previously under appreciated, such as:
- Osteoporosis and increased risk of falls
- Metabolic syndrome and increased cardiovascular mortality
- Loss of libido and erectile dysfunction
- Cognitive decline
- Cancer-related fatigue
- Decreased quality of life
PSA testing gives men the best chance of being diagnosed at a curable stage, but the lack of clear guidelines means many men present with locally advanced disease or metastatic disease, once considered beyond cure. Combination therapy is now curing these men, provable by long follow-up with negative PSA tests. So how can we do this?
MRI – Very accurate local staging allows better patient selection and precise surgical planning.
PSMA – Significantly improves extra prostatic staging, Response to therapy can be accurately monitored and responders identified.
Neoadjuvant chemotherapy – Prostate cancer primaries contain many clones, which promote treatment resistance, but ‘mets’ are oligo or monoclonal and are more susceptible to treatment at diagnosis. Responders can be offered resection of primary to reduce failure and in some cases even achieve cure. Chemotherapy resistance may come from new clones that develop after presentation.
Extended surgery – Robotics and increased experience have allowed us to safely resect cancers extending beyond the prostate. We regularly find cancers outside the prostate, invading seminal vesicles and into bladder. Previously unresectable cancers with extensive bladder invasion, rectal invasion, pelvic floor invasion or nodal metastases have been successfully resected with no increase in length of stay or complications. We have presented data at 5 years with only 8% of patients on ADT despite metastatic disease in nodes. Even without cure, by removing the primary and the bulk of the clones that develop resistance, we can fundamentally change the course of the disease. Widespread nodal resection is difficult and time consuming but can achieve clearance in many cases.
Adjuvant radiotherapy – In our hands, primary resection is achieved in over 90% of cases of extra prostatic disease. Adjuvant DXT can be used in the prostate bed, but more often is used later if a PSMA-positive site is identified at PSA recurrence. Highly accurate external beam radiation can target these sites, avoiding the need for extended use of medication.
The future – Precision medicine offers the possibility of tailored chemotherapy to treat latent micro metastatic disease. This will need DNA of the ‘mets’, only available by surgical sampling. Theranostics hold the promise of delivering high doses of radiation directly to marker positive cancer deposits, no matter where they are located.
We are at the start of a revolution in high-risk prostate cancer. As a high volume, focused prostate cancer service, we will always be at the forefront of diagnosis and treatment to achieve the best results for all men with this serious and complex cancer.
It is time to expect more for men.
Questions? Contact the editor.
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