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Variation in Management of Lymph Node Positive Prostate Cancer After Radical Prostatectomy Within a Statewide Quality Improvement Consortium - Beyond the Abstract

Patients with lymph node-positive (pN+) prostate cancer (CaP) at the time of radical prostatectomy (RP) are at high risk for disease recurrence and ultimately disease progression. One randomized controlled trial has shown that initiation of immediate and lifelong androgen deprivation therapy (ADT) is associated with improved overall survival.1 The addition of radiation therapy (RT) may also improve long-term oncologic outcomes in this population.2 However, as many as 30% of patients with pN+ CaP will never have disease recurrence after RP and could potentially be spared the morbidity of ADT or RT.3 Current guidelines recommend both initial secondary treatment and observation as appropriate for those pN+ patients without a detectable post-RP PSA. However, contemporary management trends of pN+ have not been well described.

In our recent manuscript, “Variation in Management of Lymph Node-Positive Prostate Cancer After Radical Prostatectomy within a Statewide Quality Improvement Consortium,” we evaluated how pN+ CaP is managed throughout the Michigan Urological Surgery Improvement Collaborative (MUSIC).4 We found that approximately two out of three patients with pN+ CaP receive some form of secondary treatment within the first 12 months post-RP (ADT, RT, or ADT+RT). We found that patients with high-risk disease features such as positive surgical margins and higher pathologic Gleason grade group, as well as a detectable post-RP PSA were associated with earlier initiation of secondary treatment. However, nearly one out of five patients with pN+ CaP and a detectable post-RP PSA did not receive secondary treatment by 12 months. This is particularly worrisome as this group is at high risk for disease progression. Lastly, we found wide practice level variability in secondary treatment rates of pN+ patients ranging from 28% to 79% across MUSIC practices with academic practices associated with higher 12-month secondary treatment initiation.

Our work demonstrates there is a high degree of variability in the management of pN+ CaP across a diverse and real-world consortium of urologic practices. This is likely reflective of the lack of randomized trials in this space and the complex nature of pN+ CaP. There remains a need for quality improvement to address this high level of inter-practice variation as well as more trials to optimize patient selection and modality of secondary treatment. Going forward, it will also be interesting to see how increasing utilization of PSMA-PET in the pre-operative work-up of CaP impacts this population as PSMA-PET negative/pN+ patients may represent a lower-risk population than those with positive imaging.

Written by: Daniel Triner, MD, PhD and Todd Morgan, MD, Department of Urology, University of Michigan, Ann Arbor, MI

References:

  1. Messing EM, Manola J, Sarosdy M, Wilding G, Crawford ED, Trump D. Immediate Hormonal Therapy Compared with Observation after Radical Prostatectomy and Pelvic Lymphadenectomy in Men with Node-Positive Prostate Cancer. New England Journal of Medicine. December 9, 1999;341(24):1781–1788.
  2. Touijer KA, Karnes RJ, Passoni N, Sjoberg DD, Assel M, Fossati N, et al. Survival Outcomes of Men with Lymph Node-positive Prostate Cancer After Radical Prostatectomy: A Comparative Analysis of Different Postoperative Management Strategies. Eur Urol. 2018;73(6):890–896. 
  3. Touijer KA, Mazzola CR, Sjoberg DD, Scardino PT, Eastham JA. Long-term Outcomes of Patients with Lymph Node Metastasis Treated with Radical Prostatectomy Without Adjuvant Androgen-deprivation Therapy. Eur Urol. 2014;65(1):20–25.
  4. Triner D, Daignault-Newton S, Singhal U, Sessine M, Dess RT, Caram ME V, et al. Variation in management of lymph node-positive prostate cancer after radical prostatectomy within a statewide quality improvement consortium. Urologic Oncology: Seminars and Original Investigations. 2024;42(7):220.e1-220.e8.
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Post-Prostatectomy Care: Variability in Treatment for Lymph Node Positive Prostate Cancer - Daniel Triner