Comparative effectiveness of radical prostatectomy with adjuvant radiotherapy versus radiotherapy plus androgen deprivation therapy for men with advanced prostate cancer

Abstract

BACKGROUND: Men with locally (LAPCa) or regionally advanced (RAPCa) prostate cancer are at high risk of death from their disease. Clinical guidelines support multi-modal approaches, which include radical prostatectomy (RP) followed by radiotherapy (XRT) or radiotherapy plus androgen deprivation therapy (ADT). However, limited data exists comparing these substantially different treatment approaches. Using SEER-Medicare data, we compare survival outcomes and adverse effects associated with RP+XRT vs XRT+ADT in these men. METHODS: SEER-Medicare data was queried for men with cT3-T4, N0, M0 (LAPCa) or cT3-T4, N1, M0 (RAPCa) prostate cancer. Propensity score methods were used to balance cohort characteristics between treatment arms. Survival analyses were analyzed using the Kaplan-Meier method and Cox proportional hazards models. RESULTS: From 1992 to 2009, 13,856 men (≥65 years) were diagnosed with LAPCa or RAPCa, of which 6.1% received RP+XRT vs 23.6% who received XRT+ADT. At a median follow-up of 14.6 years, there were 2189 deaths in the cohort, of which 702 were secondary to prostate cancer. Irrespective of tumor stage and Gleason score, adjusted 10-year prostate cancer-specific survival and 10-year overall survival favored men who underwent RP+XRT when compared to XRT+ADT. However, RP+XRT vs. XRT+ADT was associated with higher rates of erectile dysfunction (28% vs. 20%, p=0.0212, respectively) and urinary incontinence (49% vs. 19%, p<0.001, respectively). CONCLUSIONS: Men with LAPCa or RAPCa treated initially with RP+XRT had a lower risk of prostate cancer-specific death and improved overall survival when compared to those men treated with XRT+ADT, but experienced higher rates of erectile dysfunction and urinary incontinence.

Reply to Effectiveness of radical prostatectomy with adjuvant radiotherapy versus radiotherapy plus androgen deprivation therapy for men with advanced prostate cancer: Do we have certainties today?

“…We observed that men with locally advanced prostate cancer and/or node‐positive disease treated with radical prostatectomy and adjuvant radiotherapy had a lower risk of death from prostate cancer and improved overall survival in comparison with men treated with radiotherapy plus ADT . Our findings are analogous to data published in studies of men with localized prostate cancer, which have shown that surgery, compared with radiation, may have a greater impact in those with higher risk disease .…”

“…We agree that there are inherent limitations in the use of observational data for comparing 2 different treatment approaches. These limitations are detailed clearly in our publication’s Discussion section …”

The role of cystoprostatectomy in management of locally advanced prostate cancer: a systematic review

“…Currently, both surgery and radiation therapy were recommended as a first-line treatment option for LAPC patients [41]. There were always several controversies in treatment tactics with the consideration of patient survival and the quality of life [52][53][54][55]. But there was no doubt that surgery could provide accurate pathological stage for patients.…”

Effectiveness of radical prostatectomy with adjuvant radiotherapy versus radiotherapy plus androgen deprivation therapy for men with advanced prostate cancer: Do we have certainties today?

“…These limitations are detailed clearly in our publication's Discussion section. 1 The ideal treatment for men with high-risk prostate cancer is a subject of wide debate. Ideally, evidence to guide care is generated in the setting of prospective…”

“…In a newly published retrospective study, Jang et al had compared the survival outcomes and associated adverse effects for a large cohort of patients affected by local or regional advanced prostate cancer who underwent radical prostatectomy followed by radiotherapy (XRT) or XRT plus androgen deprivation therapy (ADT) from 1992 to 2009, and they had showed a significantly lower risk of prostate cancer–specific death and improved overall survival in the first group of patients in comparison with those men treated with XRT plus ADT.…”