Prostatectomy Not Guaranteed to be Curative in Prostate Cancer

For men with prostate cancer, radical prostatectomy, or surgical removal of the prostate, isn’t guaranteed to be curative, as one expert explained.

Among men with prostate cancer, radical prostatectomy, or surgical removal of the prostate, isn’t guaranteed to be curative, as one expert explained in an interview with CURE.

“This is recent data, that one in three men who actually get the prostate fully removed actually have [the cancer] return,” noted Dr. John Oertle. “And the PSA, that marker that looks at prostate cancer or prostate inflammation, that's only coming from the prostate, and so you start to see that one in three men have an elevated PSA, 20% to 40% depending upon the data and the studies right now, will have that PSA start to rise within 10 years after getting the prostate removed, and thinking that the prostate will be completely gone, and yet we know that actually, there's a high chance when you're going through something like this that has so many side effects associated with it.”

Oertle is the chief medical officer of Envita Medical Center, lead of the Molecular Tumor Board, and residency director at Envita Medical Centers, in Scottsdale, Arizona. He sat down with CURE to mark the observation of Prostate Cancer Awareness Month in September.

CURE: Patients may assume that prostate removal is curative. Can you explain why recurrence may be common and what factors contribute to this risk?

Oertle: Many patients think that once they get diagnosed with prostate cancer, that the standard of care model is, let's actually do surgery, even with early-stage prostate cancer, the cancer hasn't spread yet. It's still localized, still in the prostate, and they're being recommended prostatectomy. A radical prostatectomy basically means I'm going to remove the prostate with surgery, so that way the prostate can be removed, and all the cancer can be removed at the same time. And so, this is where many times people think that this is going to be curative, or the aspect of that, they also get recommended, well, instead of having an actual a human do it, let's actually do it under robotic surgery called the Da Vinci, which is a robot that a doctor uses to be able to remove the prostate.

So, with both of those cases you get this full removal of the prostate. And what, I think, oftentimes people don't understand is the data surrounding removal of the prostate is that, and this is recent data, that one in three men who actually get the prostate fully removed actually have [the cancer] return. And the PSA, that marker that looks at prostate cancer or prostate inflammation, that's only coming from the prostate, and so you start to see that one in three men have an elevated PSA, 20% to 40% depending upon the data and the studies right now, will have that PSA start to rise within 10 years after getting the prostate removed, and thinking that the prostate will be completely gone, and yet we know that actually, there's a high chance when you're going through something like this that has so many side effects associated with it.

What are some of the most significant and long-lasting side effects that these patients may face after radical prostatectomy?

I don't think guys really fully understand what they're getting into. When it comes to a removal of the prostate, side effects can be significant. Side effects can be urinary incontinence, and many times you can have urinary incontinence where you actually then are having to use pads or being able to have diapers, and this can be years down the line. The data shows that 12% of men never get rid of those symptoms, and so they're dealing with urinary leakage for the rest of their lives. You also have erectile dysfunction, and even only 30% of people that go through the surgery will regain any type of erectile health after one year after the surgery. You also have really severe effects like actual penile shortening, or difficulty with infertility, or there's actually urinary leakage in orgasm, or chronic pain. Also, men go through scarring and so they have to go through additional surgeries, even after the actual prostatectomy or their removal of the prostate, in order to be able to help regulate the organ in the system to be able to do what it needs to be able to do.

And then there's also a mental health component to that I see with these men, as far as men that undergo complete removal of the prostate, oftentimes, because of these symptoms and side effects, have issues with anxiety and depression. And so, this whole dynamic of the mental health side occurs. So, it's a lot of symptoms and side effects for what I find to be able to be, again, the concern of not actually having the guarantee that it's a true curative response.

How do multi-omic liquid biopsies improve detection of recurrence or disease spread compared with some standard imaging methods?

If you think about removal of the prostate, and you think that it's gone, but if it comes back in men, there still is cancer. Even if you try to remove all of the prostate, there still is cancer that has spread. And so this is why it's really important to use other techniques beyond just maybe an image to be able to evaluate it, because if you're dealing with a small, single cell of a cancer and it's escaped and it's already gotten out of the prostate, or it's floating around in the bloodstream, or it's in the lymph nodes, you're dealing with a single cell, you can't see that on imaging. Your CT scan, your MRI, your PET scan, is not going to pick up upon a small area of cancer cells.

And so this is where, when you're dealing with multi-omics and liquid biopsies, you're really looking at the data, or the information coming from a cancer cell that's now floating around in the bloodstream, and this is what's so beautiful, is that it is incredibly sensitive to picking up is there spread, not just is there actually cancer cells or information of the cancer that's getting into the bloodstream? But then you're also able to use that information to make treatment decisions. You're able to see how that cancer is maybe moving, spreading, what are those mutations? What are those signaling that the cancer is using to then also apply that to be able to say, how do you actually now give a precision plan to use the right medications and treatments, to be able to have a true, effective plan in place, to be able to know what's going on with your actual disease, so you can actually develop a plan to be able to really keep things in remission and to be able to really treat it effectively.

Transcript has been edited for clarity and conciseness.

For more news on cancer updates, research and education, don’t forget to subscribe to CURE®’s newsletters here.