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CANCER CAN SPREAD AFTER RADICAL PROSTATECTOMY
By Robert Cole, MD
RADICAL SURGERY RISKS
EXTRA CAPSULAR PENETRATION
Extra Capsular Penetration (ECP) is the spread of prostate cancer through the thin wall of
tissues that surround the prostate gland. This has always limited the success of removing
the prostate surgically with a prostatectomy which only removes the prostate gland. Cancer
can be left behind resulting in a "positive margin".
Doctors can predict ahead of time the chances of a positive margin before surgery is
performed, thus avoiding unnecessary surgery and its side effects. A predictive tool called
the Partins Table, is used which combines the cancer stage, Gleason Score and PSA to
calculate whether surgery or seed implantation will be the most successful. Patients having
T1-2 tumors, with a PSA less than 15 and a Gleason Score less than 7 typically have low
chances of ECP.
As the percentage of prostate involvement by cancer increases, so does the chance of ECP.
For patients with high chances of Extra Capsular Penetration (ECP), surgery should be
avoided and external beam radiation therapy added for increased cancer control.
External beam radiation should not be given to everyone with prostate cancer. At this year's
prostate cancer update in Seattle, Washington, experts from around the world convened
and agreed; many low risk patients with early stage prostate cancer can be treated by
prostate seed implantation alone (Monotherapy). One study showed these patients do not
have any survival advantage by adding external beam radiation, but they experience added
side effects.
External beam radiation is recommended in addition to seed implantation if the patient's
cancer is more aggressive and has a high risk of ECP. The number of positive biopsies
found, a Gleason grade of 7 or higher and a PSA of over 15 at the time of presentation can
predict this.
The concern about external beam radiation therapy is that there are additional risks of
damage to normal tissues such as in the rectum and bladder; resulting in persistent
bleeding. Radiation damage to the hip joints can result in fibrosis, restriction of movement,
and even require surgical hip replacement.
One additional complication of external beam radiation therapy, is impotence (loss of the
ability to maintain and erection). This side effect often does not show up for several years.
One study reported up to 50% impotence at 5 years of survival if external beam radiation
was used.