Postoperative Management of Prostate Cancer (2024)

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    July11, 2024

    MutlaySayan,MD4; DeryaTilki,MD1,2; Anthony V.D’Amico,MD, PhD3

    Author Affiliations Article Information

    • 1Department of Urology and Martini-Klinik Prostate Cancer Center, University Hospital Hamburg Eppendorf, Hamburg, Germany

    • 2Department of Urology, Koc University Hospital, Istanbul, Turkey

    • 3Department of Radiation Oncology, Brigham and Women’s Hospital and Dana Farber Cancer Institute, Boston, Massachusetts

    • 4Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts

    JAMA Oncol. Published online July 11, 2024. doi:10.1001/jamaoncol.2024.1887

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    The current standard-of-care follow-up protocol for patients who have undergone a radical prostatectomy—irrespective of prostatectomy (p) stage, margin status, or Gleason score—is monitoring with an ultrasensitive prostate-specific antigen (PSA) test and the initiation of salvage radiation therapy (RT) if the PSA level reaches or exceeds 0.1 ng/mL (to convert PSA to µg/L, multiply by 1). This practice is supported by a meta-analysis of 3 prospective randomized clinical trials (RCTs),1 which derived its conclusion from examination of the end point of progression-free survival (PFS), primarily influenced by PSA failure. However, it is important to note that the primary end point of the RADICALS-RT trial,2 the largest of the 3 RCTs included in this meta-analysis, was freedom from distant metastases (FFDM). However, as the other 2 RCTs approached the reporting of their primary end point, being PFS, a decision was made to consolidate the data and evaluate PFS, even though it was a secondary end point in the RADICALS-RT study.2

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    July 13, 2024

    Randomized Clinical Trial vs Expert Opinion

    Takeshi Takehashi, M.D, Ph.D | Health and welfare bureau

    In the RADICALS-RT trial discussed in this article, all aspects of medical practice under investigation are empirical. Despite its classification as a randomized controlled trial (RCT), its scientific and clinical validity, both internally and externally, is limited.

    Clinical practices related to prostate cancer screening, including Gleason score, surgery, radiation, and definitions of biochemical recurrence, predominantly rely on expert consensus and case series rather than robust scientific evidence. The malignant potential of screen-detected cancers remains scientifically unvalidated. Dr. Chadok's review of prostate cancer screening in the 1980s, before the introduction of PSA testing, cautioned, "Prostate cancer screening should be considered

    investigational until definitive evidence is available" [1]. Indeed, the basis of PSA screening, including factors such as Gleason score, PSA thresholds, and the introduction of the T1c stage in the TNM classification, was initially formed on expert opinion and consensus rather than rigorous scientific evidence [2].

    In 2018, the USPSTF reviewed several RCTs (PLCO, ERSPC, CAP), finding no reduction in all-cause mortality and inconsistent effects on cancer-specific mortality [3]. These trial results do not sufficiently address Dr. Chadok's concerns [1]. The SPCG4 RCT favored surgery over surveillance for clinical cancer treatment, while the ProtecT trial showed no advantage for surgery or radiation therapy over surveillance, indicating similar outcomes without treatment [3,4].

    Significant divergence exists between perspectives of public health physicians (USPSTF) and urologists, leaving healthcare professionals uncertain about the optimal approach. The USPSTF categorizes PSA screening within an early phase clinical trial or experimental context, reflecting its Grade C designation. Subsequently, urologists have developed successive guidelines through national societies and other organizations, all advocating for PSA screening [2,5].

    In the evidence hierarchy, randomized controlled trials (RCTs) stand as the gold standard, followed by prospective cohort and case-control studies. In contrast, case reports and expert opinions carry less weight. While public health physicians specialize in evidence evaluation, their focus extends beyond prostate cancer. Thus, while the USPSTF statement is grounded in evidence, guidelines from urology societies represent expert consensus.

    REFERENCE

    1. Chodak GW, World J Surg. 1989 Jan-Feb;13(1):60-4.
    2. Catalona WJ. Med Clin North Am. 2018 Mar;102(2):199-214. doi: 10.1016/j.mcna.2017.11.001.
    3. Fenton JJ, Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 May. Report No.: 17-05229-EF-1.
    4. Takahashi T. Virchows Arch. 2024 Apr 11. doi: 10.1007/s00428-024-03804-w.
    5. Van Poppel H, Eur Urol. 2021 Dec;80(6):703-711. doi: 10.1016/j.eururo.2021.07.024.

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    Sayan M, Tilki D, D’Amico AV. Postoperative Management of Prostate Cancer—Optimizing Prostate Cancer Care. JAMA Oncol. Published online July 11, 2024. doi:10.1001/jamaoncol.2024.1887

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        Postoperative Management of Prostate Cancer (2024)

        FAQs

        Postoperative Management of Prostate Cancer? ›

        You may be tired and need more rest for 3 to 4 weeks after you go home. You may have pain or discomfort in your belly or the area between your scrotum and anus for 2 to 3 weeks. You will go home with a catheter (tube) to drain urine from your bladder. This will be removed after 1 to 3 weeks.

        What is post operative care for prostate cancer? ›

        After surgery for prostate cancer

        You can expect to return to your usual activities within about 6 weeks of the surgery. Usually you can start driving again in a couple of weeks, but heavy lifting should be avoided for 6 weeks. It's common to have pain after the surgery, so you may need pain relief for a few days.

        What is the best treatment for prostate cancer after surgery? ›

        External beam radiation is an option for treating cancer that's confined to the prostate. It can also be used after surgery to kill any cancer cells that might remain if there's a risk that the cancer could spread or come back.

        What to expect after prostate cancer surgery? ›

        You'll feel drowsy because of the anaesthetic and painkillers. It takes a few weeks for you to recover after your operation. You will need to spend a few days in the hospital and then give yourself time to recover once you are home. Most people can go back to normal activities between 6 to 8 weeks after surgery.

        What should you avoid after prostate surgery? ›

        Avoid caffeine, citrus, and alcohol​because they irritate the bladder and can cause bladder spasms. Please drink plenty of water​.

        What is the home care after prostate surgery? ›

        Drink at least 8 glasses of water a day, eat a lot of fruits and vegetables, and take stool softeners to prevent constipation. Do not strain during bowel movements. For the first few weeks after surgery, take only the medicines your provider has told you to take.

        What is the most common complication of surgical treatment of prostate cancer? ›

        Urinary Incontinence

        Nearly all men will have some form of leakage immediately after the surgery, but this will improve over time and with strengthening exercises. Most men regain urinary control within a year; approximately 1 in 5 men will have mild leakage requiring the use of 1 or more pads per day long-term.

        What is the gold standard treatment for prostate cancer? ›

        Radical prostatectomy remains the gold-standard treatment for clinically localised prostate cancer.

        What is the very latest treatment for prostate cancer? ›

        Hormone therapy for biochemically recurrent prostate cancer

        In 2023, the FDA approved enzalutamide, given alone or with another drug called leuprolide, for some men who have a biochemical recurrence and are at high risk of their cancer spreading but don't have signs on regular imaging that their cancer has come back.

        What is the fastest way to recover from prostate surgery? ›

        Early walking is the key for fast recovery and return to bowel activity. It also improves blood circulation in the legs and prevents clot formation. The best way to a speedy recovery is to start walking the hallways on the day after surgery.

        What is the regret rate for prostate surgery? ›

        What the results showed. Results showed that after five years, 279 of the men (13% of the entire group) had regrets about what they had chosen. The surgically-treated men were most likely to voice unhappiness with their decision; 183 of them (13%) felt they would have been better off with a different approach.

        What is the downside of having your prostate removed? ›

        The major possible side effects of radical prostatectomy are: Urinary incontinence (being unable to control urine) Erectile dysfunction (problems getting or keeping erections)

        How does your personality change after prostate surgery? ›

        Prostate cancer treatment can cause physical side effects, but it may also affect your mental health and emotional wellbeing with low mood, mood swings, changes in memory and concentration, or anxiety or depression. These symptoms can be mild or more challenging.

        How many days rest is needed after prostate surgery? ›

        You will probably be able to go back to work or your usual activities 3 to 5 weeks after surgery. But it can take longer to fully recover.

        Why do you have to wear a bag after prostate surgery? ›

        Your first memory after the surgery will be waking up in recovery. You will have a catheter in your bladder draining urine into a bag, and the amount of urine you pass will be measured over the first night to make sure you are receiving adequate fluids. The urine is often blood-stained.

        Do you wear diapers after prostate surgery? ›

        However, for most men, regaining full control of their urine is a gradual process that takes several weeks or months. By six months, most men who were continent before the surgery no longer need pads, though some prefer to wear just a liner for security even if they do not leak.

        What are the after effects of prostate cancer operation? ›

        The most common side effects of prostate cancer surgery are urinary incontinence (the inability to control your bladder) and erectile dysfunction, or ED (the inability to achieve a full erection).

        What is the most common problem after prostatectomy? ›

        Leaking urine. Leaking of urine is one of the most common problems after prostate cancer treatment. You might find it difficult to cope with this side effect. But there are things you can do and people who can help you and your family to cope.

        How many days are you in the hospital after prostate surgery? ›

        Prostatectomy patients typically spend one night in the hospital and are usually discharged as soon as their laboratory tests are acceptable, pain is controlled and they are able to retain liquids. Patients are discharged with special catheter, which is removed during an outpatient visit 5-7 days after the operation.

        How does prostate cancer spread after prostatectomy? ›

        The cancer cells can travel through the lymphatic system or the bloodstream to other areas of the body.

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