Survival Associated with Radical Prostatectomy vs Radiotherapy for High-Risk Prostate Cancer: A Contemporary, Nationwide Observational Analysis
Jindal T, Abdollah F, and Menon M. Survival Associated with Radical Prostatectomy vs Radiotherapy for High-Risk Prostate Cancer: A Contemporary, Nationwide Observational Analysis. International Journal of Urology 2019; 26(Suppl 2):31.
International Journal of Urology
Objective The optimal primary treatment for clinically high-risk prostate cancer (PCa) is controversial as both radical prostatectomy (RP) and radiotherapy (RT) with androgen deprivation therapy [ADT], being offered. Our objective was to compare overall mortality-free survival of high-risk PCa patients treated with primary RP vs primary RT with neoadjuvant/adjuvant ADT within the National Cancer Data Base (NCDB). Methods Within NCDB, a total of 87 875 high-risk PCa patients fulfilled our inclusion criteria (53 197 in RP group and 34 678 in RT+ADT (neoadjuvant/adjuvant) group). We employed instrumental variable analysis (IVA) approach using the yearly rate of RP as the instrument. Sensitivity analyses were performed stratified according to age, comorbidity, ADT utilization and high-dose (>75.6 Gy) RT. In addition, the outcome of RP was compared to that of RT reported in three contemporary randomized controlled trails (RCTs), after selecting only those RP patients from the NCDB who fitted inclusion/exclusion criteria of these RCTs. Results On IVA, primary RP was associated with lower overall mortality compared to primary RT+ADT (hazard ratio (HR) 0.52; 95% CI, 0.47-0.57; P < 0.001). Outcomes after primary RP were found to be better than those treated with RT+neoadjuvant (HR 0.52; P < 0.001) or adjuvant ADT (HR 0.47; P < 0.001), and in those treated with high-dose RT (HR 0.54; P < 0.001). While the survival outcomes for patients treated with RT (+/-ADT) in the RCTs were not statistically different from similar patients within the NCDB, RP was associated with greater overall mortality-free survival than any arms in RCTs. Conclusions In patients with clinically high-risk PCa, primary RP is associated with an overall mortality-free survival benefit compared to primary RT+ADT, regardless of baseline characteristics.