This retrospective, observational study assessed the differences in clinical outcomes among patients with clinical node-positive (cN1) prostate cancer undergoing radiotherapy (RT) versus radical prostatectomy (RP). After propensity score matching, the 5-year overall mortality (OM), cancer-specific mortality (CSM), and other-cause mortality (OCM) rates for RT versus RP were 15.4% versus 25%, 9.3% versus 17%, and 6.1% versus 8%, respectively. After inverse probability of treatment weighting, the multivariable Cox regression model for OM produced a hazard ratio of 0.55 (P < .001), while multiple competing risks regression models produced hazard ratios of 0.49 and 0.54 for CSM and OCM, respectively (P < .001).
These findings highlight that, in comparison with RT, RP was associated with lower CSM and OCM, and should be considered for patients with cN1 prostate cancer.
Note: this forum often recommends RT over RP. I am in this category (N1)...so it is interesting to see a specific retrospective study, especially since I received RP.
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JRPnSD
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Taken together, our observations invariably indicate that RP cN1 patients exhibit lower OM, CSM, and OCM rates. This benefit in CSM and OM may originate from better RP cancer control. This can be partly explained by the fact that the use of RT for cN1 PCa could be highly limited by the absence of accurate pathological pelvic staging that only a meticulous lymph node dissection can provide. Therefore, the cytoreductive or abscopal effect related to the local treatment of the primary tumor might be reduced for RT patients.
overall mortality (OM), cancer‐specific mortality (CSM), other cause mortality (OCM)
Someday, I hope that publications will stop publishing SEER-database analyses for comparative assessment of therapies. The risk of misinterpretation is discussed by Ronald Chen:
Specifically, there are no data in the analysis you posted about whether the entire pelvic lymph node area was actually treated with radiation. They only tell you that the RT cohort had pelvic lymph nodes that were histologically confirmed by biopsy, not that they received whole pelvic RT. In the period they looked at, I'd assume very few received that potentially curative treatment. Given their more advanced age and disease characteristics, it is much more likely that the RT they received (probably to prostate only or some spot radiation) was palliative or only meant to slow progression.
from Chen.... " For each clinician interpreting retrospective results along with or in absence of clinical trial data, recognizing our own biases by following the framework outlined previously to assess the quality and believability of each study can potentially remove the greatest confounder of all. "
So, how valuable is the use of propensity score matching in overcoming some of the limitations of retrospective studies?......
As he notes , even randomized studies have limitations...hopefully fewer !
IMHO, for the average PCa patient, when various studies do not all align so as to allow an obvious conclusion, making the decision on X or Y treatment is an exercise in frustration. Adding to the difficulty is the uncertainty of probabilities of various side effects with a specific patient. Most PCa patients actually never see much in way of studies.....rely on Docs having the patient's best interest in mind, and for the Docs to be updated on all the latest studies?
As TA says, not being specific about the extent of the radiation area occludes the evaluation of radiation efficacy. On the other hand, RP alone is basically a outmoded course of treatment for even moderately advanced disease, so there’s that.
By this I mean the practice of ‘RP then wait and see’. Is that what you had? Your profile says you started ADT a year after the RP and then radiation considerably later still. Even without the Covid delay it would have been 2 years or so? This is a course of action markedly different than what I did.
I began intensive adjuvant combination therapy (ADT, Zytiga, chemo), including RT, 3 months after my RP despite negative margins and a undetectable PSA. This was suggested as a clinical trial due to my adverse pathology post op.
I do not claim to have received better treatment, but I do know RP alone vs RP plus adjuvant combination therapy is becoming more common but still controversial. Hell, RP itself is plenty controversial as it is.
I nearly had my radiation delayed by Covid too, but made it just under the wire (Feb 2020)
If I had to do it over again I would not have had RP as it led to permanent ED and incontinence despite assurances of low risk of both by the surgeon. Only to subsequently get the ‘kitchen sink’ on top of it anyway!
I was only so aggressive because I was in that clinical trial. in other words..guesswork. I didn’t know much then either. This was in 2019, the dark ages.
RP was 8/2019, Undetectable until June 2020, reached .16 PSA in Oct 2020 and then started ADT (Firmagon) and returned to Undetectable within a week and a half. Continued ADT 2/2021 with Orgovix and started radiation (38 sessions) at that time (COVID delay)...maintain ADT to date with PSA Undetectable. This after reviewing treatment plan with doctors at Sharp ,(Uro, MO, RO) and UCSD (RO). All one can do is ask questions and follow guidance offered by the "experts". I wish there were defined treatments for best results....not just random studies with varying conclusions. Tough path for APC patients.
Tough path indeed, with tough choices. I was advised toward being aggressive right away after RP. Made me wonder why I got RP at all, since my resulting chances of cure/long remission without additional treatment were not good.
The problem is surgeons used to glean information post op that couldn’t be obtained otherwise. Newer scans have changed that of course.
Is earlier combination therapy superior? Probably, but it’s certainly debatable. I was biologically young, very fit, no co morbidities. That was basically a prerequisite for the trial. Many men get turned away or decline due to toxicity (or fear of it) of the drug combo.
I figured I might as well use my condition to my advantage and do it. Again, who knows if it mattered. So far it has, but at only a year or so since return of normal testosterone levels, it’s early for sure.
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