SPCG-15: a prospective randomized study comparing primary radical prostatectomy and primary radiotherapy plus androgen deprivation therapy for locally advanced prostate cancer

A Systematic Review of Clinical Trials Comparing Radiation Therapy Versus Radical Prostatectomy in Prostate Cancer

The treatment landscape for localized and regional prostate cancer includes active surveillance, radiation therapy (RT), and radical prostatectomy (RP). Population-based studies comparing RP to radiation reveal conflicting results due to methodological flaws. This systematic review and pooled analysis of studies aim to compare cause-specific survival (CSS), overall survival (OS), disease-free survival (DFS) and toxicity outcomes, comparing RP to RT in the management of prostate cancer. This systematic review search included the PubMed, Embase, and Cochrane libraries according to the PRISMA statement with the inception of each database up to June 24, 2023. Randomized phase 2 or 3 clinical trials that compared RP to RT in prostate cancer were included. The forest plot for the Odds ratio (OR) was plotted using the Mantel-Haenszel method, and the Z test was used to assess significance. A fixed effects model was used for meta-analysis. The search yielded seven completed randomized clinical trials and four ongoing trials. The majority of complete trials had low to intermediate-risk patient populations. OR for OS was 1.00 with 95% CI, 0.71-1.41 (P-value: 0.98), CSS OR was 0.99 with 95% CI, 0.45-2.18 (P-value 0.11), OR for DFS was 1.26 with 95% CI, 0.89-1.78 (P-value 0.19) when comparing RP to RT. The rate of distant metastatic disease was 2.3% in the RP versus 2.9% in the RT at 10 years. The rate of second malignant neoplasms was 4.5% in the RP compared to 4.2% in the RT arm at 10 years. RP caused more urinary symptoms, with a predominance of the need for urinary pads and a higher incidence of sexual dysfunction, and RT caused a higher incidence of bowel symptoms, such as blood in stools and fecal incontinence. This study provides evidence that the treatment-related outcomes are similar in patients with low to intermediate-risk prostate cancer when comparing RP to RT. Multidisciplinary treatment approaches and factoring patients' values and preferences should form the cornerstone of the ideal treatment option for each patient with localized prostate cancer. Patients with prostate cancer have an equal chance of being cancer-free and alive at 10 years with either RP or RT. In terms of side effects, RP causes more urine leakage and loss of erections, whereas RT tends to cause more bowel side effects, such as blood in stools and fecal leakage.

The Impact of Radical Prostatectomy Versus Radiation Therapy on Cancer-Specific Mortality for Nonmetastatic Prostate Cancer: Analysis of an Other-Cause Mortality Matched Cohort

INTRODUCTION

Studies comparing radical prostatectomy (RP) to radiation therapy (RT) have consistently shown that patients undergoing RT have a higher risk of other-cause mortality (OCM) compared to RP, signifying poor health status of the former patients. We aimed to evaluate the impact of RP versus RT on cancer-specific mortality (CSM) over a cohort with equivalent OCM risk.

PATIENTS AND METHODS

The SEER database was queried to identify patients with nonmetastatic PCa between 2004 and 2009. Patients were matched based on their calculated 10-year OCM risk and further stratified for D'Amico Risk Score and Gleason Grade. A Cox-regression model was used to calculate the 10-year OCM risk. Propensity-score based on the calculated OCM risk were used to match RP and RT patients. Cumulative incidence curves and Competing-risk regression analyses were used to examine the impact of treatment on CSM in the matched cohort.

RESULTS

We identified 55,106 PCa patients treated with RP and 36,674 treated with RT. After match, 6,506 patients were equally distributed for RT versus RP, with no difference in OCM rates (P = .2). The 10-year CSM rates were 8.8% versus 0.6% (P = .01) for RT versus RP in patients with unfavorable-intermediate-risk (Gleason Score 4 + 3) and 7.9% versus 3.9% (P = .003) for high-risk disease. There was no difference in CSM among RT and RP patients for favorable-intermediate-risk (Gleason Score 3 + 4) and low-risk disease.

CONCLUSIONS

In a matched cohort of PCa patients with comparable OCM between the 2 arms, RP yielded a more favorable CSM rate compared to RT only for unfavorable-intermediate- and high-risk groups.

Long-term Prostate Cancer-specific Mortality After Prostatectomy, Brachytherapy, External Beam Radiation Therapy, Hormonal Therapy, or Monitoring for Localized Prostate Cancer

BACKGROUND

The optimal treatment of localized prostate cancer (PCa) remains controversial.

OBJECTIVE

To compare long-term survival among men who underwent radical prostatectomy (RP), brachytherapy (BT), external beam radiation therapy (EBRT), primary androgen deprivation therapy (PADT), or monitoring (active surveillance [AS]/watchful waiting [WW]) for PCa.

DESIGN, SETTING, AND PARTICIPANTS

This is a cohort study with long-term follow-up from the multicenter, prospective, largely community-based Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry. Men with biopsy-proven, clinical T1-3aN0M0, localized PCa were consecutively accrued within 6 mo of diagnosis and had clinical risk data and at least 12 mo of follow-up after diagnosis available.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

PCa risk was assessed, and multivariable analyses were performed to compare PCa-specific mortality (PCSM) and all-cause mortality by primary treatment, with extensive adjustment for age and case mix using the Cancer of the Prostate Risk Assessment (CAPRA) score and a well-validated nomogram.

RESULTS AND LIMITATIONS

Among 11 864 men, 6227 (53%) underwent RP, 1645 (14%) received BT, 1462 (12%) received EBRT, 1510 (13%) received PADT, and 1020 (9%) were managed with AS/WW. At a median of 9.4 yr (interquartile range 5.8-13.7) after treatment, 764 men had died from PCa. After adjusting for CAPRA score, the hazard ratios for PCSM with RP as the reference were 1.57 (95% confidence interval [CI] 1.24-1.98; p < 0.001) for BT, 1.55 (95% CI 1.26-1.91; p < 0.001) for EBRT, 2.36 (95% CI 1.94-2.87; p < 0.001) for PADT, and 1.76 (95% CI 1.30-2.40; p < 0.001) for AS/WW. In models for long-term outcomes, PCSM differences were negligible for low-risk disease and increased progressively with risk. Limitations include the evolution of diagnostic and therapeutic strategies for PCa over time. In this nonrandomized study, the possibility of residual confounding remains salient.

CONCLUSIONS

In a large, prospective cohort of men with localized PCa, after adjustment for age and comorbidity, PCSM was lower after local therapy for those with higher-risk disease, and in particular after RP. Confirmation of these results via long-term follow-up of ongoing trials is awaited.

PATIENT SUMMARY

We evaluated different treatment options for localized prostate cancer in a large group of patients who were treated mostly in nonacademic medical centers. Results from nonrandomized trials should be interpret with caution, but even after careful risk adjustment, survival rates for men with higher-risk cancer appeared to be highest for patients whose first treatment was surgery rather than radiotherapy, hormones, or monitoring.

Development of machine learning prognostic models for overall survival of prostate cancer patients with lymph node-positive

Prostate cancer (PCa) patients with lymph node involvement (LNI) constitute a single-risk group with varied prognoses. Existing studies on this group have focused solely on those who underwent prostatectomy (RP), using statistical models to predict prognosis. This study aimed to develop an easily accessible individual survival prediction tool based on multiple machine learning (ML) algorithms to predict survival probability for PCa patients with LNI. A total of 3280 PCa patients with LNI were identified from the Surveillance, Epidemiology, and End Results (SEER) database, covering the years 2000-2019. The primary endpoint was overall survival (OS). Gradient Boosting Survival Analysis (GBSA), Random Survival Forest (RSF), and Extra Survival Trees (EST) were used to develop prognosis models, which were compared to Cox regression. Discrimination was evaluated using the time-dependent areas under the receiver operating characteristic curve (time-dependent AUC) and the concordance index (c-index). Calibration was assessed using the time-dependent Brier score (time-dependent BS) and the integrated Brier score (IBS). Moreover, the beeswarm summary plot in SHAP (SHapley Additive exPlanations) was used to display the contribution of variables to the results. The 3280 patients were randomly split into a training cohort (n = 2624) and a validation cohort (n = 656). Nine variables including age at diagnosis, race, marital status, clinical T stage, prostate-specific antigen (PSA) level at diagnosis, Gleason Score (GS), number of positive lymph nodes, radical prostatectomy (RP), and radiotherapy (RT) were used to develop models. The mean time-dependent AUC for GBSA, RSF, and EST was 0.782 (95% confidence interval [CI] 0.779-0.783), 0.779 (95% CI 0.776-0.780), and 0.781 (95% CI 0.778-0.782), respectively, which were higher than the Cox regression model of 0.770 (95% CI 0.769-0.773). Additionally, all models demonstrated almost similar calibration, with low IBS. A web-based prediction tool was developed using the best-performing GBSA, which is accessible at https://pengzihexjtu-pca-n1.streamlit.app/ . ML algorithms showed better performance compared with Cox regression and we developed a web-based tool, which may help to guide patient treatment and follow-up.

Anti-metastatic effect of taraxasterol on prostate cancer cell lines

Background and purpose

Prostate cancer is the second cause of death among men. Nowadays, treating various cancers with medicinal plants is more common than other therapeutic agents due to their minor side effects. This study aimed to evaluate the effect of taraxasterol on the prostate cancer cell line.

Experimental approach

The prostate cancer cell line (PC3) was cultured in a nutrient medium. MTT method and trypan blue staining were used to evaluate the viability of cells in the presence of different concentrations of taraxasterol, and IC50 was calculated. Real-time PCR was used to measure the expression of MMP-9, MMP-2, uPA, uPAR, TIMP-2, and TIMP-1 genes. Gelatin zymography was used to determine MMP-9 and MMP-2 enzyme activity levels. Finally, the effect of taraxasterol on cell invasion, migration, and adhesion was investigated.

Findings/Results

Taraxasterol decreased the survival rate of PC3 cells at IC50 time-dependently (24, 48, and 72 h). Taraxasterol reduced the percentage of PC3 cell adhesion, invasion, and migration by 74, 56, and 76 percent, respectively. Real-time PCR results revealed that uPA, uPAR, MMP-9, and MMP-2 gene expressions decreased in the taraxasterol-treated groups, but TIMP-2 and TIMP-1 gene expressions increased significantly. Also, a significant decrease in the level of MMP-9 and MMP-2 enzymes was observed in the PC3 cell line treated with taraxasterol.

Conclusion and implications

The present study confirmed the therapeutic role of taraxasterol in preventing prostate cancer cell metastasis in the in-vitro study.

Radical prostatectomy versus external beam radiotherapy with androgen deprivation therapy for high-risk prostate cancer: a systematic review

BACKGROUND

To summarize recent evidence in terms of health-related quality of life (HRQoL), functional and oncological outcomes following radical prostatectomy (RP) compared to external beam radiotherapy (EBRT) and androgen deprivation therapy (ADT) for high-risk prostate cancer (PCa).

METHODS

We searched Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Controlled Trial Register and the International Standard Randomized Controlled Trial Number registry on 29 march 2021. Comparative studies, published since 2016, that reported on treatment with RP versus dose-escalated EBRT and ADT for high-risk non-metastatic PCa were included. The Newcastle-Ottawa Scale was used to appraise quality and risk of bias. A qualitative synthesis was performed.

RESULTS

Nineteen studies, all non-randomized, met the inclusion criteria. Risk of bias assessment indicated low (n = 14) to moderate/high (n = 5) risk of bias. Only three studies reported functional outcomes and/or HRQoL using different measurement instruments and methods. A clinically meaningful difference in HRQoL was not observed. All studies reported oncological outcomes and survival was generally good (5-year survival rates > 90%). In the majority of studies, a statistically significant difference between both treatment groups was not observed, or only differences in biochemical recurrence-free survival were reported.

CONCLUSIONS

Evidence clearly demonstrating superiority in terms of oncological outcomes of either RP or EBRT combined with ADT is lacking. Studies reporting functional outcomes and HRQoL are very scarce and the magnitude of the effect of RP versus dose-escalated EBRT with ADT on HRQoL and functional outcomes remains largely unknown.

Applying implementation frameworks to the clinical trial context

BACKGROUND

Clinical trials advance science, benefit society, and provide optimal care to individuals with some conditions, such as cancer. However, clinical trials often fail to reach their endpoints, and low participant enrollment remains a critical problem with trial conduct. In these ways, clinical trials can be considered beneficial evidence-based practices suffering from poor implementation. Prior approaches to improving trials have had difficulties with reproducibility and limited impact, perhaps due to the lack of an underlying trial improvement framework. For these reasons, we propose adapting implementation science frameworks to the clinical trial context to improve the implementation of clinical trials.

MAIN TEXT

We adapted an outcomes framework (Proctor's Implementation Outcomes Framework) and a determinants framework (the Consolidated Framework for Implementation Research) to the trial context. We linked these frameworks to ERIC-based improvement strategies and present an inferential process model for identifying and selecting trial improvement strategies based on the Implementation Research Logic Model. We describe example applications of the framework components to the trial context and present a worked example of our model applied to a trial with poor enrollment. We then consider the implications of this approach on improving existing trials, the design of future trials, and assessing trial improvement interventions. Additionally, we consider the use of implementation science in the clinical trial context, and how clinical trials can be "test cases" for implementation research.

CONCLUSIONS

Clinical trials can be considered beneficial evidence-based interventions suffering from poor implementation. Adapting implementation science approaches to the clinical trial context can provide frameworks for contextual assessment, outcome measurement, targeted interventions, and a shared vocabulary for clinical trial improvement. Additionally, exploring implementation frameworks in the trial context can advance the science of implementation through both "test cases" and providing fertile ground for implementation intervention design and testing.

Propensity score matching analysis comparing radical prostatectomy and radiotherapy with androgen deprivation therapy in locally advanced prostate cancer

To compare clinical outcomes between the use of robotic-assisted laparoscopic radical prostatectomy (RP) and radiotherapy (RT) with long-term androgen deprivation therapy (ADT) in locally advanced prostate cancer (PC), 315 patients with locally advanced PC (clinical T-stage 3/4) were considered for analysis retrospectively. Propensity score-matching at a 1:1 ratio was performed. The median follow-up period was 59.2 months (IQR 39.8–87.4). There were 117 (37.1%) patients in the RP group and 198 (62.9%) patients in the RT group. RT patients were older and had higher PSA at diagnosis, higher Gleason score grade group and more advanced T-stage (all p < 0.001). After propensity score-matching, there were 68 patients in each group. Among locally advanced PC patients, treatment with RP had a higher risk of biochemical recurrence compared to the RT group. In multivariate Cox regression analysis, treatment with RT plus ADT significantly decreased the risk of biochemical failure (HR 0.162, p < 0.001), but there was no significant difference in local recurrence, distant metastasis and overall survival (p = 0.470, p = 0.268 and p = 0.509, respectively). This information supported a clinical benefit in BCR control for patients undergoing RT plus long-term ADT compared to RP.

Characteristics of Patients in SPCG-15—A Randomized Trial Comparing Radical Prostatectomy with Primary Radiotherapy plus Androgen Deprivation Therapy in Men with Locally Advanced Prostate Cancer

Background

There is no high-grade evidence for surgery as primary treatment for locally advanced prostate cancer. The SPCG-15 study is the first randomized trial comparing surgical treatment with radiotherapy.

Objective

To describe the baseline characteristics of the first 600 randomized men in the SPCG-15 study. The study will compare mortality and functional outcomes.

Design, setting, and participants

This study is a Scandinavian prospective, open, multicenter phase III randomized clinical trial aiming to randomize 1200 men.

Intervention

Radical prostatectomy with or without consecutive radiotherapy (experimental) and radiotherapy with neoadjuvant androgen deprivation therapy (standard of care).

Outcome measurements and statistical analysis

Cause-specific survival, metastasis-free survival, overall survival, and patient-reported bowel function, sexual health, and lower urinary tract symptoms were measured.

Results and limitations

The distribution of characteristics was similar in the two study arms. The median age was 67 yr (range 45–75 yr). Among the operated men, 36% had pT3a stage of disease and 39% had pT3b stage. International Society of Urological Pathology grades 2, 3, 4, and 5 were prevalent in 21%, 35%, 7%, and 27%, respectively. Half of the men (51%) in the surgery arm had no positive lymph nodes. The main limitation is the pragmatic design comparing the best available practice at each study site leading to heterogeneity of treatment regimens within the study arms.

Conclusions

We have proved that randomization between surgery and radiotherapy for locally advanced prostate cancer is feasible. The characteristics of the study population demonstrate a high prevalence of advanced disease, well-balanced comparison groups, and a demography mirroring the Scandinavian population of men with prostate cancer at large.

Patient summary

This study, which has recruited >600 men, compares radiotherapy with surgery for prostate cancer, and an analysis at the time of randomization indicates that the study will be informative and generalizable to most men with locally advanced but not metastasized prostate cancer.

Cancer-specific mortality after radical prostatectomy vs external beam radiotherapy in high-risk Hispanic/Latino prostate cancer patients

Purpose

To test for differences in cancer-specific mortality (CSM) rates in Hispanic/Latino prostate cancer patients according to treatment type, radical prostatectomy (RP) vs external beam radiotherapy (EBRT).

Methods

Within the Surveillance, Epidemiology, and End Results database (2010–2016), we identified 2290 NCCN (National Comprehensive Cancer Network) high-risk (HR) Hispanic/Latino prostate cancer patients. Of those, 893 (39.0%) were treated with RP vs 1397 (61.0%) with EBRT. First, cumulative incidence plots and competing risks regression models tested for CSM differences after adjustment for other cause mortality (OCM). Second, cumulative incidence plots and competing risks regression models were refitted after 1:1 propensity score matching (according to age, PSA, biopsy Gleason score, cT-stage, cN-stage).

Results

In NCCN HR patients, 5-year CSM rates for RP vs EBRT were 2.4 vs 4.7%, yielding a multivariable hazard ratio of 0.37 (95% CI 0.19–0.73, p = 0.004) favoring RP. However, after propensity score matching, the hazard ratio of 0.54 was no longer statistically significant (95% CI 0.21–1.39, p = 0.2).

Conclusion

Without the use of strictest adjustment for population differences, NCCN high-risk Hispanic/Latino prostate cancer patients appear to benefit more of RP than EBRT. However, after strictest adjustment for baseline patient and tumor characteristics between RP and EBRT cohorts, the apparent CSM benefit of RP is no longer statistically significant. In consequence, in Hispanic/Latino NCCN high-risk patients, either treatment modality results in similar CSM outcome.

Comparison of radical prostatectomy and external beam radiotherapy in high-risk prostate cancer

Purpose

We evaluated clinical outcomes of high-risk prostate cancer patients receiving external beam radiotherapy (EBRT) or radical prostatectomy (RP).

Materials and Methods

Patients were classified as high-risk prostate cancer and received definitive treatment between 2005 and 2015. Patients with previous pelvic radiotherapy, positive lymph node or distant metastasis were excluded. The primary outcomes were prostate cancer-specific survival (PCSS) and distant metastasis-free survival (DMFS).

Results

Of 583 patients met the inclusion criteria (77 EBRT and 506 RP), the estimated 10-year PCSS was 97.0% in the RP and 95.9% in the EBRT (p = 0.770). No significant difference was seen in the DMFS (p = 0.540), whereas there was a trend in favor of RP over EBRT in overall survival (OS) (p = 0.068). Propensity score matching analysis with confounding variables was done, with 183 patients (66 EBRT and 117 RP) were included. No significant difference in DMFS, PCSS or OS was found.

Conclusion

Our data demonstrated similar oncologic PCSS, OS, and DMFS outcomes between EBRT and RP patients.

Therapeutic Sequences in the Treatment of High-Risk Prostate Cancer: Paving the Way Towards Multimodal Tailored Approaches

Various definitions are currently in use to describe high-risk prostate cancer. This variety in definitions is important for patient counseling, since predicted outcomes depend on which classification is applied to identify patient’s prostate cancer risk category. Historically, strategies for the treatment of localized high-risk prostate cancer comprise local approaches such as surgery and radiotherapy, as well as systemic approaches such as hormonal therapy. Nevertheless, since high-risk prostate cancer patients remain the group with higher-risk of treatment failure and mortality rates, nowadays, novel treatment strategies, comprising hypofractionated-radiotherapy, second-generation antiandrogens, and hadrontherapy, are being explored in order to improve their long-term oncological outcomes. This narrative review aims to report the current management of high-risk prostate cancer and to explore the future perspectives in this clinical setting.

A Review on the Current Treatment Paradigm in High-Risk Prostate Cancer

High-risk prostate cancer is traditionally treated with a combination of radiotherapy (RT) and androgen deprivation therapy (ADT). However, recent advancements in systemic treatment and radiotherapy have widened the spectrum of treatment for this patient population. Use of image guidance and intensity modulation, as well as the incorporation of brachytherapy, has led to safe radiotherapy dose escalation with reduced risk of recurrence. Clinical trials have helped define the role of pelvic nodal radiotherapy, the role of stereotactic ablative radiotherapy, and the optimal duration and sequencing of ADT in combination with radiotherapy. Emerging evidence has redefined the role of surgery in this cohort. Contemporary clinical trials have identified new systemic therapy options in high-risk prostate cancer. Finally, new imaging modalities including multi-parametric MRI and molecular imaging and genomic classifiers have ushered a new era in patient selection, risk stratification, and treatment tailoring.

Radical prostatectomy versus external beam radiation therapy for high-grade, clinically localized prostate cancer: Emulation of a target clinical trial

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.

Clinical characteristics and survival outcomes in patients with a high PSA and non-metastatic prostate cancer

BACKGROUND/PURPOSE

To investigate the clinical presentation and survival outcomes of patients with both a high prostate-specific antigen (PSA) value and non-metastatic prostate cancer (PC).

METHODS

In total, 2053 PC patients were managed in our institute between January 2008 and December 2014. A total of 343 (16.7%) patients who presented with PSA values > 100 ng/mL were enrolled. Non-metastatic and metastatic PC were identified in 67 (group 1) and 276 (group 2) patients, respectively. Furthermore, 75 metastatic PC patients with PSA values < 20 ng/mL were included (group 3) for comparison. All demographics and survival outcomes were retrospectively reviewed by a questionnaire.

RESULTS

Group 2 patients had a higher PSA level than did group 1 (median: 1095 vs. 283 ng/mL, p < 0.001), and a higher Gleason grade than did groups 1 and 3 (grade group 4 plus 5: 60%, 77%, and 56%, for groups 1, 2, and 3, respectively; p < 0.001). Other demographics were similar among groups. Group 1 patients survived significantly longer than group 2 and 3 in terms of overall and cancer-specific survival rates (5-year overall survival rates: 87.5%, 46.3%, and 66.9%; 5-year cancer-specific survival rates: 94.7%, 52.7%, and 68.7% for groups 1, 2, and 3, respectively). Group 1 patients receiving local definitive treatments, such as radiation therapy or cryoablation, received survival and metastasis-free benefits compared to those without local treatment.

CONCLUSION

Patients with a high PSA value were not destined to have metastatic PC. Non-metastatic PC patients with a high PSA level obtained a survival benefit from local prostate-definitive treatments.

High-Risk Prostate Cancer: A Very Challenging Disease in the Field of Uro-Oncology

Prostate cancer (PCa) is the most common cancer in males and affects 16% of men during their lifetime [...].

The Value of Real-World Data in Understanding Prostate Cancer Risk and Improving Clinical Care: Examples from Swedish Registries

Simple Summary

Real-world data (RWD), i.e., data reflecting normal clinical practice collected outside the constraints of randomised controlled trials, provide important insights into our understanding of prostate cancer and its management. Clinical cancer registries are an important source of RWD. Depending on their scope and the potential linkage to other data sources, registry-based data can be utilised to address a variety of questions including risk factors, healthcare utilisation, treatment effectiveness, adverse effects, disparities in healthcare access, quality of care and healthcare economics. This review describes the various registry-based RWD sources for prostate cancer research in Sweden (namely the National Prostate Cancer Register, the Prostate Cancer data Base Sweden (PCBaSe) and the Patient-overview Prostate Cancer) and documents their utility for better understanding prostate cancer aetiology and improving clinical care.

Abstract

Real-world data (RWD), that is, data from sources other than controlled clinical trials, play an increasingly important role in medical research. The development of quality clinical registers, increasing access to administrative data sources, growing computing power and data linkage capacities have contributed to greater availability of RWD. Evidence derived from RWD increases our understanding of prostate cancer (PCa) aetiology, natural history and effective management. While randomised controlled trials offer the best level of evidence for establishing the efficacy of medical interventions and making causal inferences, studies using RWD offer complementary evidence about the effectiveness, long-term outcomes and safety of interventions in real-world settings. RWD provide the only means of addressing questions about risk factors and exposures that cannot be “controlled”, or when assessing rare outcomes. This review provides examples of the value of RWD for generating evidence about PCa, focusing on studies using data from a quality clinical register, namely the National Prostate Cancer Register (NPCR) Sweden, with longitudinal data on advanced PCa in Patient-overview Prostate Cancer (PPC) and data linkages to other sources in Prostate Cancer data Base Sweden (PCBaSe).

The role of surgery in high risk and advanced prostate cancer: A narrative review

Patients with high-risk and advanced prostate cancer require safe and efficacious therapies likely to offer a survival advantage while minimizing the treatment-related toxicities. Improvements in the surgical technology, diagnostic modalities, radiological staging, and risk stratification have made surgery for high-risk and advanced prostate cancer a safe and feasible option. In this review, we outline the role of radical prostatectomy in high-risk localized, locally advanced, and metastatic prostate cancer. We overview available data evaluating the use of surgery in the context of a multi-modal approach and highlight ongoing trials in this area. Furthermore, the role of surgery as a non-systemic modality for metastasis-directed therapy (MDT) is also described. Emerging imaging modalities enabling more accurate staging and longer follow-up of clinical trials for prognostic endpoints are anticipated to help identify patient cohorts and treatment strategies, where the use of surgical treatments is likely to provide oncological benefits and acceptable toxicity.

Surgical management of high-risk, localized prostate cancer

High-risk prostate cancer is a heterogeneous disease that lacks clear consensus on its ideal management. Historically, non-surgical treatment was the preferred strategy, and several studies demonstrated improved survival among men with high-risk disease managed with the combination of radiotherapy and androgen deprivation therapy (ADT) compared with ADT alone. However, practice trends in the past 10-15 years have shown increased use of radical prostatectomy with pelvic lymph node dissection for primary management of high-risk, localized disease. Radical prostatectomy, as a primary monotherapy, offers the potential benefits of avoiding ADT, reducing rates of symptomatic local recurrence, enabling full pathological tumour staging and potentially reducing late adverse effects such as secondary malignancy compared with radiation therapy. Retrospective studies have reported wide variability in short-term (pathological) and long-term (oncological) outcomes of radical prostatectomy. Surgical monotherapy continues to be appropriate for selected patients, whereas in others the best treatment strategy probably involves a multimodal approach. Appropriate risk stratification utilizing clinical, pathological and potentially also genomic risk data is imperative in the initial management of men with prostate cancer. However, data from ongoing and planned prospective trials are needed to identify the optimal management strategy for men with high-risk, localized prostate cancer.

The Impact of Prostate Cancer Treatment on Quality of Life: A Narrative Review with a Focus on Randomized Data

Despite excellent oncologic outcomes, the management of localized prostate cancer remains complex and is dependent on multiple factors, including patient life expectancy, medical comorbidities, tumor characteristics, and genetic risk factors. Decades of iterative clinical trials have improved the optimization and utilization of surgical and radiation-based modalities, as well as their combinatorial use with anti-androgen and systemic therapies. While cure rates are high and converging on equivalent disease control should an upfront surgical or radiotherapeutic approach be optimized, the long-term side effects of surgical and radiation-based treatments can differ significantly in nature. Decisions regarding the selection of therapy are therefore best made in an informed and shared medical decision-making process between clinician and patient with respect to cancer control as well as adverse effects. We outline in this narrative review an understanding regarding implications of surgical and radiation treatment on quality of life after treatment, and how these data may be considered in the context of advising patients regarding the selection of therapy. This narrative review largely focuses on the quality of life data obtained from prospective randomized trials of men treated for prostate cancer. We believe this provides the best assessment of the quality of life and can be used to inform patients when making treatment decisions.

Assessing the safety and feasibility of neoadjuvant hormone and radiation therapy followed by robot-assisted radical prostatectomy for treating locally advanced prostate cancer: protocol for an open-label, dose-escalation, single-centre, phase I clinical trial

INTRODUCTION

Patients with locally advanced prostate cancer are at high risk of recurrence after definitive treatment. There are emerging data that radical prostatectomy can delay the progression of castration resistance and potentially prolong survival. Neoadjuvant radiation therapy improves local control and has shown survival benefit with favourable toxicity profiles in several other malignancies. We have designed this trial to investigate whether this combination, which theoretically maximises local control, is a safe and feasible approach for treating locally advanced prostate cancer.

METHODS AND ANALYSIS

This study is a phase I, open-label study to investigate the safety and feasibility of neoadjuvant hormone and radiation therapy followed by robot-assisted radical prostatectomy by a traditional 3+3 dose-escalation design with four planned radiation dose levels (39.6 Gy/22F, 45 Gy/25F, 50.4 Gy/28F and 54 Gy/30F). Locally advanced prostate cancer patients with positive pelvic and/or retroperitoneal lymph nodes will be recruited. The primary objective is to determine the adverse events and maximal tolerable dose (MTD) of neoadjuvant radiotherapy. Toxicity will be assessed using the National Cancer Institute Common Toxicity Criteria V.5.0.

ETHICS AND DISSEMINATION

This protocol was approved by the Institutional Review Board of Shanghai Changhai Hospital (ref. CHEC2019-070 and CHEC2019-082). The study will be performed in compliance with applicable local legislation and in accordance with the ethical principles developed by the World Medical Association in the Declaration of Helsinki 2013. Study results will be disseminated through conferences and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBERS

ChiCTR1900022716; ChiCTR1900022754.

Definitive radiotherapy for prostate cancer in Norway 2006-2015: Temporal trends, performance and survival

BACKGROUND

More studies are needed to document nation-wide use and effectiveness of curative definitive radiotherapy (Def-RT) in the treatment of prostate cancer (PCa).

PATIENTS AND METHODS

For 38,960 men diagnosed with PCa without distant metastases from 2006 to 2015 data from the Norwegian Prostate Cancer Registry and a national radiotherapy database (NoRadBase) was analyzed. Overall survival and PCa-specific mortality were described comparing EQD-2 < 74 Gy ("low-dose") with EQD-2 ≥ 74 Gy ("escalated dose").

RESULTS

Use of Def-RT decreased (27-24%) whereas the proportion of radical prostatectomies (RPs) increased (31-38%). In high-risk patients the use of RP doubled (18-36%), while the proportion of Def-RT remained stable (about 35%). Before 2010, almost a quarter of patients received low-dose Def-RT with gradual increase of escalated Def-RT thereafter. Escalated Def-RT was associated with significantly more favorable 10-year PCa-specific mortality (4.4% [95% CI: 2.7-10.7%]) than observed after low-dose Def- RT (8.8% [95% CI: 6.2-9.8%), with the most beneficial effects in high-risk patients. Our analyses indicated the need to expand the NoRadBase by consensus-based quality measures.

CONCLUSION

In this nationwide cohort, the overall use of Def-RT decreased slightly. In high-risk patients the provision of Def-RT remained stable and was accompanied by doubling of patients with RP and reduction of a "no curative treatment" strategy. Escalated dose Def-RT significantly reduced 10-year PCa-specific mortality compared to low-dose Def-RT. Aiming for cancer care equity national radiotherapy registries for PCa should regularly monitor data based on consensus-based quality measures enabling feedback to the responsible hospitals.

Comparing effectiveness of radical prostatectomy versus external beam radiotherapy in patients with locally advanced prostate cancer: A population-based analysis

Currently, the standard management for locally advanced prostate cancer (PCa) is still controversial. In our study, we aimed to compare the survival outcomes of radical prostatectomy (RP) versus external beam radiotherapy (EBRT).We conducted analyses with a large cohort of 38,544 patients from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2016). Propensity score matching, Kaplan-Meier method, and Cox proportional hazard regression were used to reduce the influence of bias and compare the overall survival (OS) and cancer specific survival (CSS). Several different sensitivity analyses including inverse probability of treatment weighting and standardized mortality ratio weighting were used to verify the robustness of the results.Totally, 33,388 men received RP and 5,156 men received EBRT with cT3-4N0M0 PCa were included in this study. According to the Kaplan-Meier curves, RP performed better in both OS and CSS compared with EBRT (P < .0001). In the adjusted multivariate Cox regression, RP also showed better OS and CSS benefits (OS: HR=0.50; 95% confidence interval [CI]: 0.46-0.54; P < .0001 and CSS: HR=0.43; 95% CI: 0.38-0.49; P < .0001). After propensity score matching, RP is still the management that can bring more survival benefits to patients. (OS: HR=0.46; 95% CI: 0.41-0.51; P < .0001 and CSS: HR = 0.41; 95% CI: 0.34-0.48; P < .0001).Our research demonstrated the significantly better survival benefits of RP over EBRT in patients with locally advanced PCa. The results of this study will provide more evidence to help clinicians choose appropriate treatment strategies.

Benefits and Risks of Primary Treatments for High-risk Localized and Locally Advanced Prostate Cancer: An International Multidisciplinary Systematic Review

CONTEXT

The optimal treatment for men with high-risk localized or locally advanced prostate cancer (PCa) remains unknown.

OBJECTIVE

To perform a systematic review of the existing literature on the effectiveness of the different primary treatment modalities for high-risk localized and locally advanced PCa. The primary oncological outcome is the development of distant metastases at ≥5 yr of follow-up. Secondary oncological outcomes are PCa-specific mortality, overall mortality, biochemical recurrence, and need for salvage treatment with ≥5 yr of follow-up. Nononcological outcomes are quality of life (QoL), functional outcomes, and treatment-related side effects reported.

EVIDENCE ACQUISITION

Medline, Medline In-Process, Embase, and the Cochrane Central Register of Randomized Controlled Trials were searched. All comparative (randomized and nonrandomized) studies published between January 2000 and May 2019 with at least 50 participants in each arm were included. Studies reporting on high-risk localized PCa (International Society of Urologic Pathologists [ISUP] grade 4-5 [Gleason score {GS} 8-10] or prostate-specific antigen [PSA] >20 ng/ml or ≥ cT2c) and/or locally advanced PCa (any PSA, cT3-4 or cN+, any ISUP grade/GS) or where subanalyses were performed on either group were included. The following primary local treatments were mandated: radical prostatectomy (RP), external beam radiotherapy (EBRT) (≥64 Gy), brachytherapy (BT), or multimodality treatment combining any of the local treatments above (±any systemic treatment). Risk of bias (RoB) and confounding factors were assessed for each study. A narrative synthesis was performed.

EVIDENCE SYNTHESIS

Overall, 90 studies met the inclusion criteria. RoB and confounding factors revealed high RoB for selection, performance, and detection bias, and low RoB for correction of initial PSA and biopsy GS. When comparing RP with EBRT, retrospective series suggested an advantage for RP, although with a low level of evidence. Both RT and RP should be seen as part of a multimodal treatment plan with possible addition of (postoperative) RT and/or androgen deprivation therapy (ADT), respectively. High levels of evidence exist for EBRT treatment, with several randomized clinical trials showing superior outcome for adding long-term ADT or BT to EBRT. No clear cutoff can be proposed for RT dose, but higher RT doses by means of dose escalation schemes result in an improved biochemical control. Twenty studies reported data on QoL, with RP resulting mainly in genitourinary toxicity and sexual dysfunction, and EBRT in bowel problems.

CONCLUSIONS

Based on the results of this systematic review, both RP as part of multimodal treatment and EBRT + long-term ADT can be recommended as primary treatment in high-risk and locally advanced PCa. For high-risk PCa, EBRT + BT can also be offered despite more grade 3 toxicity. Interestingly, for selected patients, for example, those with higher comorbidity, a shorter duration of ADT might be an option. For locally advanced PCa, EBRT + BT shows promising result but still needs further validation. In this setting, it is important that patients are aware that the offered therapy will most likely be in the context a multimodality treatment plan. In particular, if radiation is used, the combination of local with systemic treatment provides the best outcome, provided the patient is fit enough to receive both. Until the results of the SPCG15 trial are known, the optimal local treatment remains a matter of debate. Patients should at all times be fully informed about all available options, and the likelihood of a multimodal approach including the potential side effects of both local and systemic treatment.

PATIENT SUMMARY

We reviewed the literature to see whether the evidence from clinical studies would tell us the best way of curing men with aggressive prostate cancer that had not spread to other parts of the body such as lymph glands or bones. Based on the results of this systematic review, there is good evidence that both surgery and radiation therapy are good treatment options, in terms of prolonging life and preserving quality of life, provided they are combined with other treatments. In the case of surgery this means including radiotherapy (RT), and in the case of RT this means either hormonal therapy or combined RT and brachytherapy.

Development and validation of a preoperative nomogram for predicting survival of patients with locally advanced prostate cancer after radical prostatectomy

Background

For selected locally advanced prostate cancer (PCa) patients, radical prostatectomy (RP) is one of the first-line treatments. We aimed to develop a preoperative nomogram to identify what kinds of patients can get the most survival benefits after RP.

Methods

We conducted analyses with data from the Surveillance, Epidemiology, and End Results (SEER) database. Covariates used for analyses included age at diagnosis, marital status, race, American Joint Committee on Cancer (AJCC) 7th TNM stage, Prostate specific antigen, Gleason biopsy score (GS), percent of positive cores. We estimated the cumulative incidence function for cause-specific death. The Fine and Gray’s proportional subdistribution hazard approach was used to perform multivariable competing risk analyses and reveal prognostic factors. A nomogram was built by these factors (including GS, percent of positive cores and N stage) and validated by concordance index and calibration curves. Risk stratification was established based on the nomogram.

Results

We studied 14,185 patients. N stage, GS, and percent of positive cores were the independent prognostic factors used to construct the nomogram. For validating, in the training cohort, the C-index was 0.779 (95% CI 0.736–0.822), and in the validation cohort, the C-index was 0.773 (95% CI 0.710–0.836). Calibration curves showed that the predicted survival and actual survival were very close. The nomogram performed better over the AJCC staging system (C-index 0.779 versus 0.764 for training cohort, and 0.773 versus 0.744 for validation cohort). The new stratification of risk groups based on the nomogram also showed better discrimination than the AJCC staging system.

Conclusions

The preoperative nomogram can provide favorable prognosis stratification ability to help clinicians identify patients who are suitable for surgery.

Combined Modality Therapies for High-Risk Prostate Cancer: Narrative Review of Current Understanding and New Directions

Despite the many prospective randomized trials that have been available in the past decade regarding the optimization of radiation, hormonal, and surgical therapies for high-risk prostate cancer (PCa), many questions remain. There is currently a lack of level I evidence regarding the relative efficacy of radical prostatectomy (RP) followed by adjuvant radiation compared to radiation therapy (RT) combined with androgen deprivation therapy (ADT) for high-risk PCa. Current retrospective series have also described an improvement in biochemical outcomes and PCa-specific mortality through the use of augmented radiation strategies incorporating brachytherapy. The relative efficacy of modern augmented RT compared to RP is still incompletely understood. We present a narrative review regarding recent advances in understanding regarding comparisons of overall and PCa-specific mortality measures among patients with high-risk PCa treated with either an RP/adjuvant RT or an RT/ADT approach. We give special consideration to recent trends toward the assembly of multi-institutional series targeted at providing high-quality data to minimize the effects of residual confounding. We also provide a narrative review of recent studies examining brachytherapy boost and systemic therapies, as well as an overview of currently planned and ongoing studies that will further elucidate strategies for treatment optimization over the next decade.

Comparison of Radical Prostatectomy Versus Radiation and Androgen Deprivation Therapy Strategies as Primary Treatment for High-risk Localized Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

There is little level 1 evidence regarding the relative efficacy of radical prostatectomy (RP) compared with radiotherapy (RT) combined with androgen deprivation therapy (ADT) for high-risk prostate cancer.

OBJECTIVE

To conduct a systematic review and meta-analysis comparing overall and prostate cancer-specific mortality (OM and PCM) among patients with high-risk prostate cancer treated with RP or RT/ADT.

EVIDENCE ACQUISITION

We searched PubMed, Scopus, and the Cochrane Library through July 2019 covering a period since 2009. We report the results of our systematic search according to recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Adjusted hazard ratios (aHRs) were extracted for each endpoint. The risk of bias was assessed using the Newcastle-Ottawa Scale.

EVIDENCE SYNTHESIS

A total of 23 studies with low to moderate risk of bias were found to meet the inclusion criteria. In keeping with prior studies, external beam radiation therapy (XRT) without specification of ADT was associated with worse OM and PCM (aHR 1.65, 95% confidence interval [CI] 1.42-1.91, p <  0.0001: I² = 53.4%) and (aHR 1.90, 95% CI 1.61-2.23, p <  0.0001: I² = 50.4%). These associations were weaker although not entirely eliminated when comparing RT/ADT versus RP (PCM aHR 1.54, 95% CI 1.16-2.04, p =  0.002: I² = 61.5%). Combination of RT and brachytherapy (MaxRT), on the contrary, was associated with improved PCM compared with RP (aHR 0.48, 95% CI 0.30-0.78, p =  0.003: I² = 23.8%), an effect that was not significant when comparing MaxRT with the combination RP/adjuvant RT (aHR 0.81, 95% CI 0.59-1.11, p =  0.197: I² = 0%).

CONCLUSIONS

Evidence demonstrating definitive superiority of either modality is lacking. Recent studies show improved consideration of ADT, radiation dose, brachytherapy boost, and utilization of postoperative adjuvant radiation. Residual confounding continues to limit the interpretation of observational data.

PATIENT SUMMARY

In the treatment of high-risk prostate cancer, many observational studies reporting higher mortality for radiotherapy demonstrate potential for confounding. More recent studies with current standard of care radiation regimens using androgen deprivation therapy or brachytherapy boost demonstrate approaching equivalence of prostatectomy and radiation modalities. Prospective randomized trials are needed to confirm these findings.

[Current controversies in the treatment of localized prostate cancer]

In the prostate-specific antigen (PSA) era, most prostate cancers (PCa) are diagnosed in a localized stage and a plethora of therapeutic options are warranted in different clinical settings and disease stages of localized PCa. In the current narrative review, we give an overview of the current controversies in the therapeutic landscape of localized PCa and focus on organ-sparing approaches, percutaneous radiotherapy, brachytherapy as well as retropubic and robot-assisted prostatectomy by summarizing studies that have been published within the last two years.