For your consideration........recent update......
wjso.biomedcentral.com/arti...
Conclusion here...... RP seems to offer better OS but inferior results for CSS and biochemical recurrence. Brachy boost may perform better in all aspects. I think Tall_Allen has already so noted. SE profiles are different re urinary and bowel problems. Yet, this is not a randomized trial of a large number of men!!
There's a problem with using OS as a primary endpoint for men treated for localized PC. F/u is seldom long enough (15-20 years) to reach median survival. That's why ICECAP now recommends using MFS as a surrogate endpoint. As the Kishan study of very high risk men at top hospitals showed, 10-yr MFS was MUCH better for brachy boost therapy (87%) than for surgery (54%) or external beam(56%). This held true even though many (43%) surgery patients subsequently had radiation.
prostatecancer.news/2018/03...
The study I posted agrees with that, as I stated in my amended/corrected conclusion. Yes, i wondered how they determine OS , and even CSS....seems to me better numbers on BCR and MFS are logical indicators of treatment efficacy. prostatecancerfree.org uses that measure BCR in comparing treatments. Articles that are published for general population need to provide better context? Of course, most things posted here are not for amateur reading.
Thanks for clarifying the apparent contradiction.....though I suppose there could be other explanations for the apparent conflicts in endpoints.....eg treatment ages for Rt vs Rt, etc.
Have you been able to uncover some longer term comparisons for RT, etc vs focal therapies??
I already showed you what the numbers look like, didn't I?
I think you posted something with 3 yr numbers.....but maybe I'm just too forgetful.
I posted up to 10 year numbers - beyond that, they are irrelevant for radiation
With median followups of 4-6 years, how do they determine 10 yr outcomes???? I'm sure many here would welcome that explanation from a statistician ? I note that many studies raise the same question.....do they only include men who did have 10 yr FU? Extrapolate??
This happens in all retrospective analyses, but seldom in clinical trials where most patients are recruited at the start and they run the trial until all patients have been followed up for a set amount of time. When more patients are treated recently, the median f/u is lower. They do what is called a Kaplan-Meier survival curve that accounts for patients dropping in and dropping out. It accounts for the number of patients in the study at each point in time - they are able to compare the survival curves as sample size allows.
The only randomized trial examining surgery vs. radiation in this setting, SPCG-15 (clinicaltrials.gov/ct2/show..., will not be completed until 2027!
In the absence of randomized data, the debate regarding the optimal management will continue.
This study (europeanurology.com/article... concludes:
In an analysis restricted to young and healthy men presenting with high-risk localized prostate cancer, initial radical prostatectomy is associated with an overall survival benefit compared with external beam radiation therapy plus brachytherapy.
Tall_Allen (see above) provided a study with the opposite conclusion.
It could be that radical prostatectomy +adjuvant radiotherapy is more effective but have a worse functional outcome? We lack prospective randomized trials to provide a comparison between RP and RT strategies.
This kind of database analysis is useless for making this kind of determination, as Chen has pointed out (below). The NCDB lacks the comparative data needed. He points out that patient selection criteria are not completely reflected in comorbidity data. He believes that those who are selected for EBRT are just less healthy than those who can undergo anesthesia for surgery or brachytherapy (even when younger and healthier men are separated). Other unmeasured confounders include burden of disease, and patient and physician preferences.
ascopubs.org/doi/10.1200/JC...
That is why Kishan's analysis of almost 2000 men treated at 12 leading cancer centers is so convincing. Those top institutions all had complete data on patients, and physician skills and preferences tend to not be as muddy as in community practice. The downside is that it may not at all reflect what happens in community practice.
So it may be but then why so many studies beginning with a statement like: "The optimal treatment for men with high-risk localized or locally advanced prostate cancer (PCa) remains unknown." ( Like this one from 2020europeanurology.com/article...
And with conclusions different from Kishan. This will not be settled until randomized trials have been done or ...?
I agree that RCTs are needed to resolve the issue definitively. But because high risk patients are few and far between, it is a difficult group to run a clinical trial on. Then it takes many years to get results. Meanwhile, the best we can do is go with the highest level evidence we have, which so far, is Kishan's study. Database analyses are useless.
Thanks for the excellent article on the challenges of using imperfect data when doing comparative studies.
f/u ? What is f/u ?
Abbreviation for follow up.
Abbreviation for when I married my first wife..... I really f/u
Good Luck, Good Health and Good Humor.
j-o-h-n Thursday 01/21/2021 7:03 PM EST
Interesting, but for those here like me who were g 9/10 and stage 4 at diagnosis and still had RP as first line treatment, It means little. No RT acct wide spread into nerves and veins out of prostate area and throughout whole pelvic area... Removed mother ship and given 12-18 mo max. Started Lupron then taxotere and xtandi ( concurrently for cycles 5-9). Pushed aPca into remission. So other treatment studies would be much more informative for me...Probably not enough 'out of the box' patients like me to get useful info.
You're right. This is a site for advanced PC, so this stuff is useless for patients on this forum.
A striking point noted in the study is that "notably, very few (11%) of the EBRT patients had both ≥ 78 Gy and ≥2 years of ADT, a combination that is now considered standard of care. Those that did had superior outcomes compared to RP". Bear in mind that the science and application of EBRT has moved on significantly since the underlying research was conducted and that the use of Abiraterone is now more widespread as a frontline treatment for newly diagnosed high risk patients with positive LN involvement. The implication for patients in this latter cohort is that a Brachy boost would not provide any additional benefit and would almost certainly be prejudicial to QOL.
Comparative Effectiveness of Radical Prostatectomy vs EBRT Plus Brachytherapy in High-Risk Localized Prostate Cancer
Docetaxel vs Surveillance After Radical Radiotherapy for Intermediate- or High-Risk Prostate Cancer 
Postoperative or Salvage Proton Radiotherapy for Prostate Cancer After Radical Prostatectomy
Survival after radical prostatectomy or radiotherapy for locally advanced (cT3) prostate cancer.
Radiotherapy In The Definitive Management Of Oligometastatic Prostate Cancer
