Radical Prostatectomy vs External Beam Radiation Therapy for High-Grade, Clinically Localized Prostate Cancer

[Balsam01]

TAKE-HOME MESSAGE

This retrospective study sought to emulate a randomized trial comparing outcomes between prostatectomy and radiation therapy for high-grade (Gleason score 8–10), clinically localized prostate cancer. The data were extracted from the National Cancer Database (2006–2015) and propensity scoring was used to account for between-group baseline differences. In all, 23,990 patients were treated with radical prostatectomy and 2816 with radiation + androgen deprivation therapy. Unadjusted 5-year and 10-year overall survival was 93% and 77% respectively, for surgery; 85% and 55%, respectively for radiation. The marked survival benefit persisted following propensity-scoring adjustment, with HR for surgery of 0.54.

These findings suggest a clinically significant survival benefit for surgery over radiation in this setting.

– Joshua A. Cohn, MD

Abstract

This abstract is available on the publisher's site.

PURPOSE

The comparative effectiveness of surgery and radiation therapy for high-grade, clinically localized prostate cancer remains a seminal, open question in urologic oncology, with no randomized controlled trials to inform management. We therefore emulated a hypothetical target clinical trial of radical prostatectomy (RP) versus external beam radiotherapy (EBRT) for high-grade, clinically localized prostate cancer.

MATERIALS AND METHODS

We conducted observational analyses using the National Cancer Database from 2006-2015 to emulate a target clinical trial in men 55-69 years with cT1-3cN0cM0, PSA<20 ng/mL, Gleason 8 to 10 prostate adenocarcinoma treated with RP or 75 to 81 Gy EBRT with androgen deprivation therapy (EBRT+ADT). The associations of treatment type with overall survival (OS) were estimated using Cox regression with stabilized inverse probability weights (IPW).

RESULTS

A total of 26,806 men formed the study cohort (RP: 23,990; EBRT+ADT: 2,816). Baseline characteristics were well-balanced after IPW-adjustment. Median follow-up was 48.4 (IQR 25.5-76.2) months. After IPW-reweighting, RP was associated with improved OS compared to EBRT+ADT (HR 0.54;95% CI 0.48-0.62; P<0.001), with 5- and 10-year OS of 93% vs 87%, and 76% vs 60%, respectively. RP was associated with improved OS across all categories of Gleason score, PSA, cT stage, age, and Charlson comorbidity index examined. In sensitivity analyses adjusting for biopsy tumor volume and a biopsy-specific Gleason score, RP remained associated with improved OS compared to EBRT+ADT (HR 0.62;95% CI 0.49-0.78; P<0.001).

CONCLUSIONS

In observational analyses designed to emulate a target clinical trial of men with high-grade, clinically localized prostate cancer, RP was associated with improved OS compared with EBRT+ADT.

Citation: Urologic Oncology: Seminars & Original Investigations

Radical Prostatectomy Versus External Beam Radiation Therapy for High-Grade, Clinically Localized Prostate Cancer: Emulation of a Target Clinical Trial

Urol. Oncol 2021 Apr 29;[EPub Ahead of Print], C Reitblat, A Fleishman, IA Kaplan, KD Stensland, AV D'Amico, AF Olumi, AA Wagner, PK Chang, SP Kim, R Korets, B Gershman

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

[Hidden]

Since I fit into this high risk clinically localized group I certainly hope this is true. The true test is time. If I don't report back in ten years, it's incorrect.

[Balsam01]

To me, you have always been the biggest proponent of the benefits of the "debulking" hypothesis--get rid of the mothership!

[Shooter1]

Well, I had the RP as all was expected to be advanced / localized Pca. Scans were wrong. It was everywhere in abdomen and new scans show bones also. Great info for those with correct scans when making a decision. Still think it was the right decision, but only time will tell. Scan later today may give more info on that front.

[tango65]

This is the link to the full article:

reader.elsevier.com/reader/...

This is a retrospective study, not a RCT.

[Spyder54]

Great study. Thank you. These were N0, M0 cases from what I read. So many of us have lymph node and or bone metastisis. A study with N1, M1 would be of interest to many of us.

Mike

[Gemlin_]

No RCT will ever be done to prove it, but I believe that it is very likely that RP has better survival than radiation at the expense of worse side effects. Difficult choice for many, really difficult!

[Largebill]

Best of luck whichever decision you make. It's important to remember it is your decision. Doctors make recommendations - patients make decisions. When I was diagnosed, it was believed that the PC was confined to my prostate which made RALP seem like the right decision for me. If you go that route, recommend getting it the habit of long walks. Being more fit helps with tolerating any treatment. It will help after surgery in regaining control of your bladder.