Martini-Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
Martini-Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
Eur Urol. 2015 Aug;68(2):175-8. doi: 10.1016/j.eururo.2015.02.020. Epub 2015 Feb 27.
The use of prostate-specific antigen (PSA) for screening or early detection of prostate cancer (PCa) results in significant stage migration toward more favorable stages and a proven decrease in PCa mortality but is accompanied by substantial rates of overdiagnosis and overtreatment. Acknowledgement of these downsides and endeavors to avoid them have led to substantial changes in treatment patterns. Many centers have reported dramatic changes, with increases in active surveillance (AS) of early cancers and local treatment of advanced disease. To estimate the impact of this development on our radical prostatectomy (RP) series, we analyzed changes in cancer and patient selection over the past 15 yr. Despite a trend toward decreased utilization of RP in Germany, the annual caseload at our institution increased due to regionalization, from 382 RPs in 2000 to 2145 in 2011, and has been stable for the past 3 yr (2106 RPs in 2014). The rate of RPs performed in patients with low-risk PCa, AS candidates, or men with a pure Gleason 6 pattern in the RP specimen dropped from 60%, 38.2%, and 56.2%, respectively, in 2004 to 27%, 14.7%, and 10%, respectively, in 2011-2013. Patients undergoing RP with solely Gleason 6 cancer were younger on average (aged 61 yr) than patients in higher risk groups (aged 65 yr). The rate of histologically insignificant PCa was low, ranging from 1% to 8.8% depending on the definition used. Patient selection is the other important tool used to avoid overtreatment. Long-term other-cause mortality (OCM) should be low in adequately selected RP candidates, and after a minimum follow-up of 15 yr, overall OCM was 14.8%. The OCM rate was 10.2% in men aged <65 yr and 24.3% in men aged ≥65 yr. The current analysis documents a clear shift in utilization of RP toward significant PCa in men with long life expectancy. Based on patient and cancer selection as described, the long-standing discussion of overtreatment with RP might become invalid.
Discussion of possible overtreatment has led to dramatic changes in indication for radical prostatectomy (RP). We analyzed a large European patient cohort and found that RP is rarely done in early cancers but is used more for aggressive tumors. Those who underwent RP had long life expectancy and benefit from surgery. With this change in application, overtreatment with RP is unlikely.
使用前列腺特异性抗原（PSA）进行前列腺癌（PCa）的筛查或早期检测可显著改变肿瘤分期，有利于更有利的分期，并已证实降低 PCa 死亡率，但同时伴随着大量的过度诊断和过度治疗。认识到这些缺点并努力避免这些缺点导致治疗模式发生了重大变化。许多中心报告了显著的变化，包括早期癌症的主动监测（AS）和晚期疾病的局部治疗增加。为了评估这一发展对我们根治性前列腺切除术（RP）系列的影响，我们分析了过去 15 年中癌症和患者选择的变化。尽管德国 RP 的使用率呈下降趋势，但由于区域化，我院的年度病例数从 2000 年的 382 例增加到 2011 年的 2145 例，并且在过去 3 年中保持稳定（2014 年为 2106 例）。在低危 PCa、AS 候选者或 RP 标本中仅有 Gleason 6 模式的男性中，行 RP 的比例分别从 2004 年的 60%、38.2%和 56.2%下降到 2011-2013 年的 27%、14.7%和 10%。仅行 Gleason 6 癌症 RP 的患者平均年龄较轻（61 岁），而处于较高风险组的患者年龄较大（65 岁）。根据所使用的定义，组织学上无意义的 PCa 发生率较低，范围为 1%至 8.8%。患者选择是避免过度治疗的另一个重要工具。在经过充分选择的 RP 候选者中，长期其他原因死亡率（OCM）应该较低，在至少 15 年的随访后，总 OCM 为 14.8%。在年龄<65 岁的男性中，OCM 率为 10.2%，在年龄≥65 岁的男性中，OCM 率为 24.3%。目前的分析表明，在预期寿命较长的男性中，RP 的使用率明显向显著的 PCa 转移。基于所描述的患者和癌症选择，关于 RP 过度治疗的长期讨论可能变得无效。
关于可能过度治疗的讨论导致 RP 适应证发生了重大变化。我们分析了一个大型欧洲患者队列，发现 RP 很少用于早期癌症，但更多地用于侵袭性肿瘤。那些接受 RP 的人预期寿命较长，并且从手术中受益。随着这种应用的改变，RP 的过度治疗不太可能。
