The survival impact of neoadjuvant hormonal therapy before radical prostatectomy for treatment of high-risk prostate cancer

BACKGROUND

Several randomized controlled trials assessed the outcomes of patients treated with neoadjuvant hormonal therapy (NHT) before radical prostatectomy (RP). The majority of them included mainly low and intermediate risk prostate cancer (PCa) without specifically assessing PCa-related death (PCRD). Thus, there is a lack of knowledge regarding a possible effect of NHT on PCRD in the high-risk PCa population. We aimed to analyze the effect of NHT on PCRD in a multicenter high-risk PCa population treated with RP, using a propensity-score adjustment.

METHODS

This is a retrospective multi-institutional study including patients with high-risk PCa defined as: clinical stage T3-4, PSA >20 ng ml^-1 or biopsy Gleason score 8-10. We compared PCRD between RP and NHT+RP using competing risks analysis. Correction for group differences was performed by propensity-score adjustment.

RESULTS

After application of the inclusion/exclusion criteria, 1573 patients remained for analysis; 1170 patients received RP and 403 NHT+RP. Median follow-up was 56 months (interquartile range 29-88). Eighty-six patients died of PCa and 106 of other causes. NHT decreased the risk of PCRD (hazard ratio (HR) 0.5; 95% confidence interval (CI) 0.32-0.80; P=0.0014). An interaction effect between NHT and radiotherapy (RT) was observed (HR 0.3; 95% CI 0.21-0.43; P<0.0008). More specifically, of patients who received adjuvant RT, those who underwent NHT+RP had decreased PCRD rates (2.3% at 5 year) compared to RP (7.5% at 5 year). The retrospective design and lack of specific information about NHT are possible limitations.

CONCLUSIONS

In this propensity-score adjusted analysis from a large high-risk PCa population, NHT before surgery significantly decreased PCRD. This effect appeared to be mainly driven by the early addition of RT post-surgery. The specific sequence of NHT+RP and adjuvant RT merits further study in the high-risk PCa population.

[Tissue engineering in reconstructive urology]

The term tissue engineering incorporates various techniques for the production of replacement tissues and organs. In urology tissue engineering offers many promising possibilities for the reconstruction of the urinary tract. Currently, buccal mucosa and urothelial cells are most commonly used for tissue engineering of the urinary tract. Various materials have been tested for their suitability as tissue scaffolds. The ideal scaffold, however, has not yet been found. In addition to material sciences and cell culture methods, surgical techniques play an important role in reconstructive urology for the successful implantation of tissue engineered transplants.

[Quality of care in patients with newly diagnosed bladder cancer: a prospective assessment in northern Germany]

INTRODUCTION

The aim of this study was to evaluate the current quality of care in newly diagnosed bladder cancer patients in a regional representative sample of German urologists.

MATERIAL AND METHODS

Using a standardized questionnaire clinical and pathological data from over 400 patients with newly diagnosed urothelial carcinoma of the bladder (UCB) between January and December 2010 were collected from urology health care practitioners in northern Germany. As diagnostic and therapeutic decisions were not influenced by a specific protocol these findings represent current regional practice patterns.

RESULTS

Complete data of 359 patients were available for analysis. The median patient age at diagnosis was 72 years (range 29-98 years) with a male:female ratio of 3:1. The main reasons for transurethral resection of the bladder (TURB) were microhematuria (45.4 %), conspicuous ultrasound findings (12.8 %) and gross hematuria (11.7 %). Using photodynamic diagnosis (PDD) TURB was performed in 78 patients (21.7 %). The results of histopathology showed papillary urothelial neoplasm of low malignant potential (PUNLMP) in 8 patients (2.2 %), pTa in 202 (56.3 %), pTis in 7 (1.9 %), pT1 in 88 (24.5 %) and ≥pT2 bladder cancer in 54 (15 %) patients. Multiple tumors were recorded in 107 patients (29.8 %). A repeat TURB was performed in 130 patients (36.8 %) in a median of 45 days and residual tumor tissue was found in 79 of these patients (60.8 %). Immediate postoperative instillation chemotherapy was performed in 152 patients (42.3 %) and adjuvant intravesical maintenance therapy was performed in 142 patients (39.6 %, mitomycin 29.2 % vs. BCG 10.4 %). Patients treated with repeat TURB or adjuvant instillation therapy were more likely to have higher tumor stages and grades (p-values< 0.001). Overall 25 patients (7.7 %) experienced disease recurrence within 3 months. Lower tumor stage and grade, performance of repeat TURB and administration of adjuvant intravesical therapy were associated with reduced early disease recurrence (p-values ≤ 0.009).

CONCLUSIONS

The current study presents contemporary findings and practice patterns in patients with newly diagnosed bladder cancer. Interestingly, the rates of immediate postoperative instillation chemotherapy and maintenance intravesical therapy were lower than expected. Utilization of PDD-TURB is still underrepresented. Remarkable is the high number of patients with residual tumor in the repeat TURB. Differences in patient counselling, hospital practice standards and compliance factors most likely contribute to variations in guideline adherence.