EURURO Vol. 71 No. 4

E113 692

Letter to the Editor
Re: Pa¨r Stattin, Fredrik Sandin, Frederik Birkebæk
Thomsen, et al. Association of Radical Local
Treatment with Mortality in Men with Very
High-risk Prostate Cancer: A Semiecologic,
Nationwide, Population-based Study. Eur Urol.
In press.
Radical Treatment in Very High-risk Prostate Cancer:
Venturing Down a Path Less Travelled
Recently, high-risk prostate cancer has been thrown in the
limelight of discussion. We commend the authors for such a
great semiecologic study design tackling areas not yet well
addressed. According to the large observational study
presented by Stattin et al surgery offers better survival
among men with prostate cancer. Using data from the
national prostate cancer register of Sweden, they analyzed
differences in treatment selection on categorized exposure
to treatment centers. Their results show that men with very
high-risk prostate cancer who were treated at centers with a
higher proportion of radical local treatment had a lower
mortality rate ratio (MRR 0.51) compared to patients
treated at centers with the lowest proportion of radical
treatments.
Although these results make sense, the extent of lymph
node dissection (LND) was not clearly stated. It is important
to note that the outcomes for pelvic LND (PLND) may be
influenced by the operating surgeon . Therefore, one
may presume that patients at centers with a larger
proportion of radical treatments may have undergone
surgery performed by surgeons with greater experience in
LND, yielding better outcomes than would otherwise have
been expected .
We examined our data from a high-volume tertiary care
center with a high-volume surgeon (K.H.R.) and found 86%
cancer-specific survival at 66-mo follow-up among patients
with very high-risk prostate cancer (n = 166) after robot-
assisted radical prostatectomy with extended PLND (un-
published data). These findings suggest that more extensive
PLND offers better survival outcomes among prostate
cancer patients, in accordance with other studies .
Stattin and colleagues only reported the number of
lymph node invasions, and the number of actual LNDs not
presented. Arguably, this may or may not have affected the
oncologic results of their study. Moreover, it might not only
be exposure to radical treatment that brought about better
outcomes for patients, but also the performance of highly
experienced surgeons. Nonetheless, our findings suggest
that the results observed in Sweden may be true and can be
seen even among Asian patients.
The authors further confirmed the merit of radical
prostatectomy by demonstrating a better survival benefit.
In a previous study, we likewise found satisfactory
oncologic outcomes for very high-risk prostate cancer
patients after PLND, with acceptable postoperative com-
plications (p = 0.239), albeit with a lower continence rate of
32% (p = 0.013) . Therefore, it would be prudent for
readers to balance the survival advantage and postoperative
complications of surgical intervention that were not
discussed by Stattin et al. Nevertheless, these observational
findings may further inform the surgical management of
very high-risk prostate cancer while we await results from
randomized controlled trials.
Conflicts of interest: The authors have nothing to disclose.
References
[1] Stattin P, Sandin F, Thomsen FB, et al. Association of radical local
treatment with mortality[6_TD$DIFF] in men with very high-risk prostate
cancer: a semiecologic, nationwide, population-based study. Eur
Urol. In press. .
[2]
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[3]
[4]
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ava ilable at
journal homepage:
DOI of original article: .
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.