Using SEER–Medicare data, this study compared survival outcomes and adverse effects associated with radical prostatectomy (RP) plus radiotherapy (XRT) versus XRT plus androgen deprivation therapy (ADT) in 13,856 men with cT3-T4N0M0 locally advanced (LAPCa) or cT3-T4N1M0 regionally advanced (RAPCa) prostate cancer. For patients who underwent RP plus XRT, 10-year prostate cancer–specific survival and 10-year overall survival rates were improved compared with those who underwent XRT plus ADT. Relative to patients receiving XRT plus ADT, rates of erectile dysfunction and urinary incontinence were higher in patients receiving RP plus XRT.
The study authors concluded that men with LAPCa or RAPCa treated initially with RP plus XRT had both reduced risk of prostate cancer–specific death and improved overall survival relative to men who were treated with XRT plus ADT."
Prostate cancer treatment keeps advancing and it's always difficult to figure out how the treatment practices of the past apply to today's treatment. For example, we know that the lower doses of radiation given in the 1990's were less effective than the higher doses given today. We also know that new radiation modalities became important in the 2000s, especially brachytherapy and IMRT. Therefore, it would be valuable to have the results of the study broken down by year of treatment rather than averaged. Similarly, it wasn't until the early 2000's that ADT began to be combined with radiation and given for increasing lengths of time. And of course while the higher doses with ADT may have raised survival rates, they may have also increased the side effects.
Another question involves how radiation was given after surgery. If it was done shortly after surgery at least one study I've read says the results would be better than if the doctors waited until after an identified recurrence. So it's possible that the best practice of today for high risk disease might also improve the surgical outcomes.
Then there are the patient selection issues. In the past, and maybe still today, radiation was given more to older and/or sicker men and surgery to younger and healthier ones. It's hard to know if that was a factor in the study.
I don't mean by any of this to argue that radiation is as good as surgery + radiation for this type of patient. I just don't know what's best. I think what we have here is a useful datapoint that gives some evidence in favor of surgery + radiation, but it's not a certainty.
Very well stated. I am polymetastatic and chose RT after chemo based on the information available at the time. The doctors said I could have either RP or RT but not both, so I chose the latter hoping for an abscopal effect while on ADT. Phil
It would seem like there are so many variations of surgical styles and skill. And even more so with respect to radiation, that which is better may be hard to accurately tease out of this data.
I would expect the results vary more my Doc than by RT vs RP.
Given the rapid advances in radiation technology in the past 10 years - any study claiming to give valid results that is based on treatments given prior to the current practices is questionable at best, and as pointed out - patient age bias also is a strong factor in the selection of treatments. Many urologists (mine included) did suggest that surgery was not a great choice for men over 70, the outcome and recovery was more difficult and the side effects more likely and severe.
ncbi.nlm.nih.gov/pmc/articl... - this paper is not a comparison of different treatments (RP, RRP, EBRT) - but a report on a specific protocol using IG/IMRT and longer term ADT for higher risk patients. It also covers only the period of time since that therapy has been being used - so the oldest results are about 6 years.. but it is encouraging when this treatment is considered. It's what I chose - at the suggestion of my urologist, my medical oncologist, and my radiation oncologist. They each came up with the suggestion independently once I said surgery was not on the table (due to comorbidities).
I expect by the time 5 years pass by - there will be newer and better treatment options if that is necessary.
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Survival Outcomes of Radical Prostatectomy vs EBRT in Prostate Cancer Patients With Gleason Score 9–10 at Biopsy 
PSA Nadir After RT+ADT for Prostate Cancer Predicts Outcomes
