How should lymph node-positive prostate cancer be treated?

[tonymax]

There’s an interesting article on the PracticeUpdate web site: Lymph Node–Positive (N1M0) Prostate Cancer: What Is the Evidence for Nihilism?  http://www.practiceupdate.com/expertopinion/909

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Tony said ...

Historically it has been assumed that patients with lymph node-positive, non-metastatic (N1M0) prostate cancer were incurable as they probably already had micrometastases (even though no metastasis was visible on bone or CT scans).  These patients were not offered any localised treatment (such as prostatectomy and/or radiotherapy) but were only given systemic treatment (hormone therapy).

Where lymph node-positive disease is discovered in sites such as breast, lung, and colorectal cancer, it is treated aggressively with multimodality therapy.  Why should lymph node-positive disease in prostate cancer be treated any differently?  Why should lymph node-positive disease in prostate cancer regarded as incurabile?

Recently a comparative analysis of local therapy (prostatectomy, radiation, or both) vs no local therapy was undertaken with data captured by the Surveillance, Epidemiology, and End Results program of the US National Cancer Institute for nearly 4,000 patients diagnosed with lymph node-positive, non-metastatic prostate cancer from 1995 to 2005.

The analysis suggested that local therapy for men with node-positive prostate cancer seems to have lead to improvements in median overall survival of 3.7 and 5.3 years in clinical and pathologic cohorts of their study population (as compared to no local treatment but systemic treatment with androgen deprivation).  The researchers also claimed that benefits could be observed across subgroups, notably including patients ≥70 years and those with advanced nodal disease.

Even though it used retrospective, population-based data, this analysis challenges the “Do Nothing” approach to lymph node-positive, non-metastatic prostate cancer.

One wonders why the medical scientific community has not been more proactive on multi modal treatment strategies.

There are some interesting possible connections in the article and the references quoted in it to other current speculations – eg getting rid of primary tumours stops their signals to facilitate cancer spread – my experience is not incompatible with that.