Survival after radiotherapy vs. radical prostatectomy for unfavorable intermediate-risk prostate cancer

[pjoshea13]

New study below [1].

"Highlights

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"There was no difference in survival between radical prostatectomy (RP) and EBRT + BT.

•

"RP had better survival compared to EBRT alone and brachytherapy alone.

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"There was no significant difference in survival between RP and brachytherapy plus ADT or EBRT >7920 cGy and ADT."

...........

"We queried the National Cancer Database for patients with unfavorable intermediate-risk prostate cancer, as defined by the National Comprehensive Cancer Network. We compared overall survival between patients treated with radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy, and EBRT plus brachytherapy (EBRT+BT) ..."

"We found no statistically significant difference in survival between RP and EBRT+BT.

"EBRT and brachytherapy had higher mortality, respectively, compared to RP.

"When including only radiotherapy patients who received ADT and, in the case of EBRT, a total dose ≥ 7920 cGy, there was no statistically significant difference in survival when comparing RP to EBRT or brachytherapy."

-Patrick

[1] sciencedirect.com/science/a...

Survival after radiotherapy vs. radical prostatectomy for unfavorable intermediate-risk prostate cancer

Author links open overlay panelNikhil T.SebastianM.D.aJoseph P.McElroyPh.D.bDouglas D.MartinM.D.aDebasishSundiM.D.cDayssy AlexandraDiazM.D.a

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doi.org/10.1016/j.urolonc.2... rights and content

Highlights

•

There was no difference in survival between radical prostatectomy (RP) and EBRT + BT.

•

RP had better survival compared to EBRT alone and brachytherapy alone.

•

There was no significant difference in survival between RP and brachytherapy plus ADT or EBRT >7920 cGy and ADT.

Abstract

Background

The optimal treatment for unfavorable intermediate-risk prostate cancer is unknown. Given the lack of randomized evidence, large comparative studies may be useful in guiding clinical decision-making.

Methods

We queried the National Cancer Database for patients with unfavorable intermediate-risk prostate cancer, as defined by the National Comprehensive Cancer Network. We compared overall survival between patients treated with radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy, and EBRT plus brachytherapy (EBRT+BT) using Cox proportional hazards models and propensity score matching.

Results

A total of 10,439 patients were analyzed. There was no statistically significant difference in overall survival between RP and EBRT+BT (hazard ratio [HR] = 1.24; 95% confidence interval [CI] 0.58–2.65). RP was associated with higher survival when compared to EBRT (HR = 2.30, 95% CI 1.70–3.20) and brachytherapy (HR = 2.90, 95% CI 1.40–6.20). When accounting for androgen deprivation therapy (ADT), there was no statistically significant difference in survival between RP and brachytherapy with ADT (HR = 3.08; 95% CI 0.62–15.27) or EBRT to a dose of ≥7920 cGy with ADT (HR = 2.6, 95% CI 0.50–13.20).

Conclusion

We found no statistically significant difference in survival between RP and EBRT+BT. EBRT and brachytherapy had higher mortality, respectively, compared to RP. When including only radiotherapy patients who received ADT and, in the case of EBRT, a total dose ≥ 7920 cGy, there was no statistically significant difference in survival when comparing RP to EBRT or brachytherapy. These findings should be prospectively studied.

Keywords

Prostatic neoplasmsRadiationBrachytherapyCombined modality therapyProstatectomy

[cesanon]

I'm not certain how these two statements are not contradictory?

1. "We found no statistically significant difference in survival between RP and EBRT+BT.

2. "EBRT and brachytherapy had higher mortality, respectively, compared to RP.

[Graham49 in reply to cesanon]

Presumably, for (2) it means EBRT alone and brachytherapy alone?

[cesanon in reply to Graham49]

Ohhh, maybe.

[Don_1213 in reply to cesanon]

There are other studies showing the same. Modern EBRT + ADT has equal or better survival rates to RP. When I say "Modern" - I'm referring to treatments done on advanced image guided machines and a total dose of 81Gy or above.

One other consideration of the mortality numbers is selection bias. Typically healthy men below 70 years of age are offered RP. Their health is perhaps the key to the survival numbers. Men with comorbidities (high blood pressure, heart disease, etc) and men over 70 are frequently referred to RT of some sort.

Also note - this is a retrospective study, based on a database. There is no mention of the qualifying factors used to select which data was used. Using results from older treatment regiemes, especially with RT which has advanced rapidly in the past 10 years may also tend so slant the output a bit.

Reading these reports is always interesting - but I also like to try and determine how and where the study data was obtained, and if it was a double-blind test, or simply a restudy of data gathered some time ago.

[cesanon in reply to Don_1213]

"I'm referring to treatments done on advanced image guided machines and a total dose of 81Gy or above."

So are you saying the modern approach is high dose radiation?

If so, that makes me feel better about my choice of the Dattoli clinic for radiation treatment back a few years ago. I think they used 76Gy, which was I am told very high... At least at the time.

So maybe they were ahead of the times?

[Don_1213 in reply to cesanon]

The latest RT treatments for high-risk PCa is pretty much settled on >80Gy. 81Gy is fairly common since it's 45 treatments at 1.8Gy per treatment and with modern equipment it's well tolerated by patients.

It's also done in 2 phases - the first phase - 25 treatments is done with coverage of the prostate bed and the surrounding lymph nodes and the prostate itself. The final 20 treatments (ie - "boost" phase) emulates brachy by concentrating on the prostate only.

That's the current "standard of care" - along with 2 years of ADT for high-risk cancer.

[cesanon in reply to Don_1213]

Well looks like I sort of got that about 10 years ago. Except they added Brachytherapy to it.

Though it does seem they burned out my CD4 T-cells in the process. LOL

[NPfisherman]

Thanks for posting, Patrick...our most prolific poster and researcher... God bless you for what you do here...

Don Pescado

[cesanon in reply to NPfisherman]

Yes. Thanks Patrick

[Hidden]

The statistics in 2003 showed a 92% success rate with a Gleason 7 for either Prostecomy or Brachytherapy + IMRT.

GD

[bobdc6]

Bottom line, go with whatever treatment is offered near where we live?

[Don_1213 in reply to bobdc6]

I don't think that's necessarily a good selection criteria. Go with what makes sense for your condition and your accessability to treatment.

[bobdc6 in reply to Don_1213]

Well, I went 800 miles for proton when I could have gotten radiation or RP locally. I'm satisfied with what I chose, but maybe it didn't make any difference in the long run. Time will tell.

[Don_1213 in reply to bobdc6]

I think it's really a question of the risk level of the cancer you're trying to eliminate. Using proton with a low grade prostate cancer (G6, G7) probably is as effective short and long term as any other treatment, and may well be superior due to lower side-effects. With higher risk PCa (G8-G10, PSA > 20) the numbers so far are not as clear. There may be a better result vs older RT treatments, but I have been told (by several medical oncologists) that the proof just isn't there for high-risk use - yet. As more people do proton treatments (several US facilities are being built as we discuss this - primarily for use with juvenile cancers) - that answer should become clearer.

[Don_1213 in reply to bobdc6]

FWIW - I did consider proton as an option. The facility was new, very clean, the RO seemed very straightforward and competant. It would have meant a 100 mile round trip daily to get treated (too close to motel it, and too far to be a trivial drive).

I finally settled on IG/IMRT/W-ARC treatment at a hospital nearby. One deciding factor was the radiation tech who would be doing it is a very good friend. I knew that care would be given in the treatments.

The other is the facility was brand new with the latest equipment, and the RO was very good about sitting down and talking to me without waiting days or weeks for an appointment. I got to talk to him the day after I asked to. He spent a good hour with me comparing the treatments, and the expected results and side effects. He has remained in contact since treatments concluded. Had the 3 month followup a few days ago, and have been in contact via email since that. His email responses are always within 24 hours, and typically less than 4 hours.

[cesanon in reply to bobdc6]

"Bottom line, go with whatever treatment is offered near where we live?"

I can think of no good reason for such a policy.

If you do not find yourself flying around to major medical centers getting multiple second opinions, whatever it is you are optimizing, it is not your health.

If you start and stop at the nearest most convenient urologist, that will asymptotically increase your likelihood of getting an incomplete diagnosis, and getting butchered, regardless of whether that is the best option for you.

[bobdc6 in reply to cesanon]

My thoughts exactly.

[LeeLiam]

Since survival between RP and EBRT+BT is about the same, I wish they would do a similar comparison of long term side effects. That was the tiebreaker for me so I chose EBRT+BT.

[Don_1213 in reply to LeeLiam]

I've seen those numbers out there somewhere, but again - with the advances in RT in general and increasing precision it's done with, side-effects are likely decreasing while effectiveness of the treatment is increasing. If you see a long-term study on any sort of RT - it's generally for a type of treatment that is no longer done today, which puts in question the validity of the results.

[tallguy2]

Thank you for posting this.