Surgery vs Radiotherapy for Gleason 9-10.

[pjoshea13]

New study below.

I think that surgery was not considered to be a good option for GS=9/10 in 2004.

"Can treatment with radical prostatectomy, adjuvant external beam radiotherapy, and androgen deprivation therapy (termed MaxRP) or external beam radiotherapy, brachytherapy, and androgen deprivation therapy (termed MaxRT) in men with Gleason score 9-10 prostate cancer provide similar survival outcomes?"

"Among 639 men, this cohort study found no significant difference after MaxRP or MaxRT in prostate cancer–specific and all-cause death risk, with plausibility indexes for equivalence of 76.75% for prostate cancer–specific mortality risk and 77.97% for all-cause mortality risk."

"It is plausible that treatment with MaxRP or MaxRT for men with Gleason score 9-10 prostate cancer provides equivalent survival outcomes."

"Discussion

"In this study, we first validated the prior finding3 of a significantly reduced PCSM risk in men with biopsy Gleason score 9-10 prostate cancer when treated using MaxRT compared with RP but with a median ADT duration of 6 months as opposed to 12 months. Specifically, the point estimate of the AHR for the risk of PCSM comparing MaxRT with RP in the present study was 0.36 (1 divided by 2.80), which is similar to the previous report3 of 0.38. While prospective validation is needed in a randomized clinical trial, this result provides evidence to support that, in the setting of EBRT and brachytherapy, adding 6 months compared with 12 months of ADT may provide a similar PCSM risk reduction compared with RP.

"Second, when assessing the likelihood of equivalence in the risk of PCSM and ACM after treatment using the plausibility index, men undergoing MaxRP had the highest likelihood of achieving equivalent risk of PCSM and ACM compared with men undergoing MaxRT. Lending further support to this result, we observed that, despite having more adverse postoperative prostate cancer prognostic factors compared with men undergoing RP, who fared worse than men undergoing MaxRT, men undergoing MaxRP did not have an increased risk of PCSM or ACM when compared with men undergoing MaxRT, whereas men who underwent RP plus adjuvant ADT without EBRT did. The clinical significance of these observations is that they provide evidence to support the importance of adding both adjuvant EBRT and ADT after RP in men with biopsy Gleason score 9-10 prostate cancer to reduce the risk of PCSM and ACM so that their outcomes may become comparable to those of men undergoing MaxRT.

"Some points require further discussion. First, while not significant, men undergoing RP plus adjuvant RT had an AHR for PCSM and ACM risk less than 1.0, which can be explained by the more favorable baseline distribution of prostate cancer prognostic factors in men undergoing RP plus adjuvant RT vs MaxRT, in addition to the significantly shorter median follow-up of 3.87 vs 5.51 years (P = .03), providing less time to observe deaths. Moreover, when treatment with RP plus adjuvant RT was evaluated for possible equivalence with MaxRT using the plausibility index, the values were 58.24% and 62.32% for the risk of PCSM and ACM, respectively, which were lower compared with the respective values of 76.75% and 77.97% for men treated with MaxRP.

"Second, while a prior study22 has shown that at least 75% of men undergoing RP for biopsy Gleason score 9-10 prostate cancer will have at least 1 adverse pathologic factor at RP (ie, extraprostatic extension, seminal vesicle invasion, R1, or N1) and thus have an indication for adjuvant EBRT and/or ADT, only 33.5% (187 of 559) of men received adjuvant EBRT, ADT, or both in the present study. The reason for the low use of adjuvant EBRT in the post-RP setting arises from the concerns regarding overtreatment in the current era in which PSA monitoring after RP is routinely practiced and early salvage EBRT at the time of PSA failure can occur. Specifically, the 3 randomized adjuvant EBRT trials4-6 were conducted during the pre-PSA and early PSA era. As a result, the observation arm of those studies started salvage EBRT later then would be practiced today, appropriately calling into question whether the earlier use of salvage EBRT would be as effective as adjuvant EBRT. This observation led to the formation of 2 randomized clinical trials (Radiotherapy–Adjuvant Versus Early Salvage [RAVES; NCT00860652] and Radiation Therapy and Androgen Deprivation Therapy in Treating Patients Who Have Undergone Surgery for Prostate Cancer [RADICALS; NCT00541047]) that together will help to determine the influence of timing (ie, adjuvant or early salvage), type (ie, EBRT, ADT, or both), and duration of ADT (none, 6 months, or 2 years) on the long-term end points, including recurrence-free and prostate cancer–specific survival. Based on the Surveillance, Epidemiology, and End Results database, only 5.2% of men have prostatectomy Gleason score 9-10 prostate cancer after RP,23 and RAVES (NCT00860652) and RADICALS (NCT00541047) did not stratify men by prostatectomy Gleason score 9-10 vs 8 or less prostate cancer before randomization; as a result, any benefit in the prostatectomy Gleason score 9-10 prostate cancer subset to adjuvant vs early salvage may be diluted by the more common lower-risk subsets of prostatectomy Gleason score 7 and 8 prostate cancer and not observed. This fact emphasizes the importance of our results, which provide the only available evidence to date to support the contention that the use of both adjuvant EBRT and ADT in men with biopsy Gleason score 9-10 prostate cancer may reduce the risk of PCSM to that seen after MaxRT. Moreover, this potential reduction in PCSM risk is accompanied by minimal, if any, risk of overtreatment given the high rate of PSA failure, being at least 80% by 15 years after RP19 and which necessitates the subsequent use of salvage EBRT and ADT."

-Patrick

Full Text:

jamanetwork.com/journals/ja...

[snoraste]

Part of the problem here is that for some, including myself, there are no hot spots left to radiate after RP, given you need to be on ADT to shrink the size of the prostate before surgery.

[Fairwind]

Radiation treatment has made HUGE advancements since 2004....Surgery has not changed very much...Either way, G-9 or 10 is hard to beat....

[pjoshea13 in reply to Fairwind]

Unfortunately, someone using 10-year survival data say, to make a treatment decision, is necessarily relying on radiation norms of 10+ years ago.

-Patrick