Commenatry on Gautam G. Is it truly outrageous to consider radical prostatectomy for men with metastatic prostate cancer? Indian J Urol 2014;30:366-7.

The concept of radical prostatectomy for metastatic prostate cancer is interesting. The rationale of debulking in metastatic cancer is derived from the experience in gastric and ovarian carcinomas where debulking and systemic chemotherapy have shown a survival benefit. The essential difference between adenocarcinoma prostate and these cell types is the absence of an equally effective chemotherapeutic regimen for prostate cancer. Hormonal ablation alone invariably leads to castration resistant disease in the course of time.

Patients who received local therapy in the SEER study could be a highly selected group. A retrospective analysis, particularly from a registry, has disadvantages. The reasons for selecting a treatment may not be adequately documented. Further, the comparisons would be biased if the groups (without surgery or radiation therapy) were not adequately matched. In fact, in this study, they are unmatched. The prostate specific antigen (PSA) levels were >30 ng/dl in 61.6% of patients of the no surgery or radiation group but only 13 % of patients in the radical prostatectomy group had similar levels of PSA. The grade and exact TNM stage was unknown in a significant number of patients in the no surgery group while the documentation was much better in the local therapy group, perhaps an example of selection bias.[1]

The paper using data from the Munich cancer registry also suffers from similar issues. The groups and unmatched and per se the patients who underwent radical prostatectomy had lesser disease bulk than those who did not.[2] The message that comes out of this research is that there appears to be a role for lymphadenectomy in radical prostatectomy and the subset of patients who may have disease that has not spread beyond the regional lymph nodes may have the greatest benefit from this approach.[3]

Cytoreductive surgery has been tried in renal cell carcinoma (along with targeted therapy with tyrosine kinase inhibitors), with reports of improved survival in a retrospective series. However, the benefit was minimal in poor risk disease.[4] The question for renal cell carcinoma is likely to be answered with the multinational, prospective, randomized trial that is underway (CARMENA: NCT00930033).

For a similar trial to be attempted in carcinoma prostate, it will have to be powered to detect differences in outcome in the subset analysis as benefit, if any, is likely to be seen in a highly selected group. At the moment, based on current evidence, cytoreductive prostatectomy in metastatic disease remains investigational.