Characterizing Surgical and Radiotherapy Outcomes in Non-metastatic High-Risk Prostate Cancer: A Systematic Review and Meta-Analysis

Background Identifying the optimal management of high-risk non-metastatic prostate cancer (PCa) is an important public health concern, given the large burden of this disease. We performed a meta-analysis of studies comparing PCa-specific mortality (CSM) among men diagnosed with high-risk non-metastatic PCa who were treated with primary radiotherapy (RT) and radical prostatectomy (RP). Methods Medline and Embase were searched for articles between January 1, 2005, and February 11, 2020. After title and abstract screening, two authors independently reviewed full-text articles for inclusion. Data were abstracted, and a modified version of the Newcastle-Ottawa Scale, involving a comprehensive list of confounding variables, was used to assess the risk of bias. Results Fifteen studies involving 131,392 patients were included. No difference in adjusted CSM in RT relative to RP was shown (hazard ratio, 1.02 [95% confidence interval: 0.84, 1.25]). Increased CSM was found in a subgroup analysis comparing external beam radiation therapy (EBRT) with RP (1.35 [1.10, 1.68]), whereas EBRT combined with brachytherapy (BT) versus RP showed lower CSM (0.68 [0.48, 0.95]). All studies demonstrated a high risk of bias as none fully adjusted for all confounding variables. Conclusion We found no difference in CSM between men diagnosed with non-metastatic high-risk PCa and treated with RP or RT; however, this is likely explained by increased CSM in men treated with EBRT and decreased CSM in men treated with EBRT + BT studies relative to RP. High risk of bias in all studies identifies the need for better data collection and confounding control in the PCa research.

The role of radical prostatectomy and definitive external beam radiotherapy in combined treatment for high-risk prostate cancer: a systematic review and meta-analysis

The first-line treatment options for high-risk prostate cancer (PCa) are definitive external beam radiotherapy (EBRT) with or without androgen deprivation therapy (ADT) and radical prostatectomy (RP) with or without adjuvant therapies. However, few randomized trials have compared the survival outcomes of these two treatments. To systematically evaluate the survival outcomes of high-risk PCa patients treated with EBRT- or RP-based therapy, a comprehensive and up-to-date meta-analysis was performed. A systematic online search was conducted for randomized or observational studies that investigated biochemical relapse-free survival (bRFS), cancer-specific survival (CSS), and/or overall survival (OS), in relation to the use of RP or EBRT in patients with high-risk PCa. The summary hazard ratios (HRs) were estimated under the random effects models. We identified heterogeneity between studies using Q tests and measured it using I² statistics. We evaluated publication bias using funnel plots and Egger's regression asymmetry tests. Seventeen studies (including one randomized controlled trial [RCT]) of low risk of bias were selected and up to 9504 patients were pooled. When comparing EBRT-based treatment with RP-based treatment, the pooled HRs for bRFS, CSS, and OS were 0.40 (95% confidence interval [CI]: 0.24–0.67), 1.36 (95% CI: 0.94–1.97), and 1.39 (95% CI: 1.18–1.62), respectively. Better OS for RP-based treatment and better bRFS for EBRT-based treatment have been identified, and there was no significant difference in CSS between the two treatments. RP-based treatment is recommended for high-risk PCa patients who value long-term survival, and EBRT-based treatment might be a promising alternative for elderly patients.

Current and emerging therapies for localized high-risk prostate cancer

Introduction: Despite progress in the field of high-risk localized prostate cancer (HRPCa) treatments, high-risk patients treated with curative intent are at increased risk of biochemical recurrence, metastatic progression and cancer-related death. The optimal treatment strategy remains a topic of debate. This review provides an overview of the current and investigational therapeutic options for HRPCa.Areas covered: A PubMed search was performed for papers on the current perspectives on the multimodality treatment of HRPCa. We focus on both primary local treatment as well as systemic treatment options. Finally, relevant ongoing trials focusing on systemic treatments (including [neo]adjuvant treatments) enrolling at least 50 patients were retrieved, to highlight ongoing research and treatment optimization.Expert opinion: Disease progression in HRPCa patients is driven by local tumor extension and subclinical metastases. Therefore, the main treatment concept is a multimodal approach targeting the primary tumor with extended surgery or RT with long-term ADT and simultaneously targeting micro-metastatic deposits. However, there is still room for optimization. Upcoming clinical trials comparing surgery versus RT as local treatment, trials with (neo)adjuvant chemotherapy or androgen receptor signaling inhibitors will likely change the treatment landscape. However, a multimodal treatment strategy will stay as the cornerstone in the treatment of HRPCa.

Updated evidence on oncological outcomes of surgery versus external beam radiotherapy for localized prostate cancer

Radical prostatectomy and external beam radiotherapy are recognized as comparable treatment options for localized prostate cancer. Previous studies of oncological outcomes of surgery versus radiotherapy have reported their comparability or possible superiority of surgery. However, the issue of which treatment is better remains controversial. Several factors make fair comparison of their outcomes difficult: different patient backgrounds caused by selection bias, different definitions of biochemical recurrence and different complication profiles between the treatment modalities. In 2016, the first large randomized controlled trial was published, which compared radical prostatectomy, external beam radiotherapy and active monitoring in localized prostate cancer. More recently, another study has reported comparative outcomes of robot-assisted radical prostatectomy and volumetric modulated arc therapy, as the leading surgery and radiotherapy techniques, respectively. Furthermore, there has been a trend toward combining external beam radiotherapy with brachytherapy boost, especially in patients with high-risk prostate cancer. This review summarizes the updated evidence on oncological outcomes of surgery versus external beam radiotherapy for localized prostate cancer.

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.

Significance of Time Until PSA Recurrence After Radical Prostatectomy Without Neo- or Adjuvant Treatment to Clinical Progression and Cancer-Related Death in High-Risk Prostate Cancer Patients

Objective: The aim of our study was to evaluate the impact of time until biochemical recurrence (BCR) after radical prostatectomy (RP) without neo- or adjuvant treatment on clinical progression (CP) and cancer-related death (CRD) in high-risk prostate cancer (HRPCa) patients. Materials and methods: A total of 433 men with clinically HRPCa treated between 2001 and 2017 were identified. HRPCa was defined as clinical stage ≥T2c and/or biopsy Gleason score (GS) ≥8 and/or preoperative prostate specific antigen (PSA) value ≥20 ng/ml. Exclusion criteria were neo- or adjuvant treatment and incomplete pathological or follow-up data. BCR was defined as two consecutive PSA values ≥0.2 ng/ml after RP. CP was identified as skeletal lesions, local or loco-regional recurrence. CRD was defined as death from PCa. All men were divided into two groups according to BCR. The chi-square and t-tests were used to compare baseline characteristics between groups. Biochemical progression free survival (BPFS), clinical progression free survival (CPFS), and cancer-specific survival (CSS) rates were estimated using Kaplan-Meier analysis. Patients with detected BCR were analyzed for prediction of CP and CRD with respect to time until BCR. The impact of baseline parameters on BCR, CP, and CRD was assessed by Cox regression analysis. Results: BCR, CP, and CRD rates were 47.8% (207/433), 11.3% (49/433), and 5.5% (24/433), respectively. Median (quartiles) time of follow-up after RP was 64 (40-110) months. Ten-year BPFS rate was 34.2%; CPFS, 81%; and CSS, 90.1%. Men with detected BCR were analyzed for prediction of CP and CRD with respect to time until BCR. The most informative cutoff for time from RP until CP and CRD was ≤ 1 year (p < 0.008). According to this cutoff, men were divided into two groups: BCR detected within 1 year and after a 1-year period. Ten-year CPFS was 49.8% in men with early BCR vs. 81.1% in men with late BCR; CSS was 70.9 vs. 92.8% (p = 0.001). Multivariable analysis confirmed that time until BCR within 1 year predicts CP (p = 0.005) and CRD (p = 0.03). Conclusions: Early BCR is associated with poorer oncological outcomes. The presented results may help both to improve follow-up strategy and opt for more aggressive multimodal treatment of HRPCa in men with very early BCR.

Comparative effectiveness of surgery versus external beam radiation with/without brachytherapy in high-risk localized prostate cancer

BACKGROUND

It remains controversial if radical prostatectomy or definitive radiation therapy produces equivalent outcomes in high-risk localized prostate cancer.

METHODS

We queried The Surveillance, Epidemiology, and End Results (SEER) database for those who received upfront surgery or who were recommended for surgery but instead received radiation. Inverse probability of treatment weighing was used to adjust for covariate imbalance and the weighted Cox proportional hazards model was used to estimate the effects of treatment groups on survival. A meta-analysis was performed to pool estimates from published studies.

RESULTS

Among eligible 62 533 patients, 59 540 had upfront surgery and 2993 patients had upfront radiotherapy. EBRT + BT was associated with a superior cancer-specific survival (CSS) compared with surgery or EBRT alone (HR, 0.55, 95% CI, 0.3-1.0; HR, 0.49, 95% CI, 0.24-0.98, respectively), whereas EBRT was associated with an inferior overall survival (OS) compared with surgery (HR, 1.46, 95% CI, 1.16-1.8). Radiotherapy (EBRT ± BT) was inferior to surgery by OS (HR, 1.63, 95% CI, 1.13-2.34) in patients ≤ 65 years, and was superior to surgery by CSS in patients > 65 years (HR, 0.69, 95% CI, 0.49-0.97). The meta-analysis showed consistent results.

CONCLUSION

EBRT + BT was associated with a significantly better prostate CSS compared with surgery or EBRT. EBRT alone was inferior to surgery by OS.

Differences in overall survival and cancer-specific survival in high-risk prostate cancer patients according to the primary treatment

INTRODUCTION AND OBJECTIVES

There is no high-level evidence as to which primary treatment provides an overall survival (OS) or cancer-specific survival (CSS) advantage in high-risk localised prostate cancer (HRLPC). Our aim was to analyse the differences in survival and predictive factors in this group of patients, according to their primary treatment (radical prostatectomy (RP) or radiotherapy and androgen blockade (RT+HT)).

MATERIAL AND METHODS

A retrospective study of 286 HRLPC patients diagnosed between 1996-2008, treated by RP (n=145) or RT+HT(n=141). Survival was assessed using the Kaplan-Meier method. Significant differences between the different variables were analysed using the log-rank test. A uni and multivariate Cox regression analysis was performed to identify risk factors.

RESULTS

the median follow-up was 117.5 (IQR 87-158) months. The OS was longer (p=.04) in the RP patients, while there were no differences (P=.44) in CSS between either group. The type of primary treatment was not related to OS or CSS. Age (P=.002), the onset during follow-up of a 2nd tumour (P=.0001), and stage cT3a (P=.009) behaved as independent predictive variables of OS. None of the variables behaved as an independent predictive variable of CSS, although biochemical recurrence after rescue treatment (P=.058), and the onset of a 2nd tumour during follow-up showed a significant trend to statistical significance, the latter reducing specific cancer mortality (HR .16, 95%CI .02-1.18, P=.07).

CONCLUSIONS

Primary treatment did not relate to OS or CSS in patients with HRPC.

Efficacy and Safety of Robotic Procedures Performed Using the da Vinci Robotic Surgical System at a Single Institute in Korea: Experience with 10000 Cases

PURPOSE

To evaluate the efficacy and safety of robotic procedures performed using the da Vinci Robotic Surgical System at a single institute.

MATERIALS AND METHODS

We analyzed all robotic procedures performed at Severance Hospital, Yonsei University Health System (Seoul, Korea). Reliability and mortality rates of the robotic surgeries were also investigated.

RESULTS

From July 2005 to December 2013, 10267 da Vinci robotic procedures were performed in seven different departments by 47 surgeons at our institute. There were 5641 cases (54.9%) of general surgery, including endocrine (38.0%), upper (7.7%) and lower gastrointestinal tract (7.5%), hepato-biliary and pancreatic (1.2%), and pediatric (0.6%) surgeries. Urologic surgery (33.0%) was the second most common, followed by otorhinolaryngologic (7.0%), obstetric and gynecologic (3.2%), thoracic (1.5%), cardiac (0.3%), and neurosurgery (0.1%). Thyroid (40.8%) and prostate (27.4%) procedures accounted for more than half of all surgeries, followed by stomach (7.6%), colorectal (7.5%), kidney and ureter (5.1%), head and neck (4.0%), uterus (3.2%), thoracic (1.5%), and other (2.9%) surgeries. Most surgeries (94.5%) were performed for malignancies. General and urologic surgeries rapidly increased after 2005, whereas others increased slowly. Thyroid and prostate surgeries increased rapidly after 2007. Surgeries for benign conditions accounted for a small portion of all procedures, although the numbers thereof have been steadily increasing. System malfunctions and failures were reported in 185 (1.8%) cases. Mortality related to robotic surgery was observed for 12 (0.12%) cases.

CONCLUSION

Robotic surgeries have increased steadily at our institution. The da Vinci Robotic Surgical System is effective and safe for use during surgery.

Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part I: Risk Stratification, Shared Decision Making, and Care Options

PURPOSE

This guideline is structured to provide a clinical framework stratified by cancer severity to facilitate care decisions and guide the specifics of implementing the selected management options. The summary presented represents Part I of the two-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline discussing risk stratification and care options by cancer severity.

MATERIALS AND METHODS

The systematic review utilized in the creation of this guideline was completed by the Agency for Healthcare Research and Quality and through additional supplementation by ECRI Institute. This review included articles published between January 2007 and March 2014 with an update search conducted through August 2016. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. Additional information is provided as Clinical Principles and Expert Opinions (table 2 in supplementary unabridged guideline, http://jurology.com/).

RESULTS

The AUA (American Urological Association), ASTRO, and SUO (Society of Urologic Oncology) formulated an evidence-based guideline based on a risk stratified clinical framework for the management of localized prostate cancer.

CONCLUSIONS

This guideline attempts to improve a clinician's ability to treat patients diagnosed with localized prostate cancer, but higher quality evidence in future trials will be essential to improve the level of care for these patients. In all cases, patient preferences should be considered when choosing a management strategy.

Cancer-specific mortality of high-risk prostate cancer after carbon-ion radiotherapy plus long-term androgen deprivation therapy

The treatment outcomes of patients with high‐risk localized prostate cancer (PC) after carbon‐ion radiotherapy (CIRT) combined with long‐term androgen deprivation therapy (LTADT) were analyzed, and compared with those of other treatment modalities, focusing on PC‐specific mortality (PCSM). A total of 1247 patients were enrolled in three phase II clinical trials of fixed‐dose CIRT between 2000 and 2013. Excluding patients with T4 disease, 608 patients with high‐risk or very‐high‐risk PC, according to the National Comprehensive Cancer Network classification system, who received CIRT with LTADT were evaluated. The median follow‐up time was 88.4 months, and the 5‐/10‐year PCSM rates were 1.5%/4.3%, respectively. T3b disease, Gleason score of 9–10 and percentage of positive biopsy cores >75% were associated with significantly higher PCSM on univariate and multivariate analyses. The 10‐year PCSM rates of patients having all three (n = 16), two (n = 74) or one of these risk factors (n = 217) were 27.1, 11.6 and 5.7%, respectively. Of the 301 patients with none of these factors, only 1 PCSM occurred over the 10‐year follow‐up (10‐year PCSM rate, 0.3%), and significant differences were observed among the four stratified groups (P <0.001). CIRT combined with LTADT yielded relatively favorable treatment outcomes in patients with high‐risk PC and very favorable results in patients without any of the three abovementioned factors for PCSM. Because a significant difference in PCSM among the high‐risk PC patient groups was observed, new categorization and treatment intensity adjustment may be required for high‐risk PC patients treated with CIRT.

Treatment of locally advanced prostate cancer (Stage T3)

Objective

Formerly, locally advanced prostate cancer exhibited poorly prognosis. In the late 1990s, new surgical and radiation technologies were introduced in combination with androgen deprivation. To evaluate respective strategies, outcomes were examined.

Patients and methods

Between 2001 and 2010, 224 patients with T3N0M0 (10.9% of all prostate cancer cases) were treated with prostatectomy, external beam radiation therapy with/without androgen deprivation or hormone alone. Complete records were obtained by the end of 2015.

Results

Operation group first started without adjuvant treatment and prostate-specific antigen (PSA) relapse occurred in 39% of cases. Radiation therapy group was alternatively divided into two subgroups, that received either monotherapy or combination with androgen deprivation, and PSA relapse rates were 65 and 16%, respectively. High rates of PSA relapse in both the operation and radiation therapy groups were observed in patients without adjuvant therapy, but after relapse androgen deprivation proceeded favorable outcomes. In the radiation subgroups, PSA relapse rates were different, but both subsequent survival rates were the same. This may be due to the effect of androgen deprivation after relapse, indicating effect of delayed therapy. PSA relapse rate in the hormone therapy group was 25% and after relapse, patients applied to treatment with other hormonal and anticancer drugs. Overall survival rates were 91, 88 and 67% in the operation, radiation therapy and hormone therapy groups, respectively.

Conclusion

Aggressive treatment with short-term androgen deprivation for locally advanced prostate cancer could be beneficial and not harmful when suitable candidates are selected. Delayed androgen deprivation was effective for no adjuvant patients after PSA relapse.

Comparative effectiveness of prostate cancer treatments for patient-centered outcomes: A systematic review and meta-analysis (PRISMA Compliant)

BACKGROUND

In the context of prostate cancer (PCa) characterized by the multiple alternative treatment strategies, comparative effectiveness analysis is essential for informed decision-making. We analyzed the comparative effectiveness of PCa treatments through systematic review and meta-analysis with a focus on outcomes that matter most to newly diagnosed localized PCa patients.

METHODS

We performed a systematic review of literature published in English from 1995 to October 2016. A search strategy was employed using terms "prostate cancer," "localized," "outcomes," "mortality," "health related quality of life," and "complications" to identify relevant randomized controlled trials (RCTs), prospective, and retrospective studies. For observational studies, only those adjusting for selection bias using propensity-score or instrumental-variables approaches were included. Multivariable adjusted hazard ratio was used to assess all-cause and disease-specific mortality. Funnel plots were used to assess the level of bias.

RESULTS

Our search strategy yielded 58 articles, of which 29 were RCTs, 6 were prospective studies, and 23 were retrospective studies. The studies provided moderate data for the patient-centered outcome of mortality. Radical prostatectomy demonstrated mortality benefit compared to watchful waiting (all-cause HR = 0.63 CI = 0.45, 0.87; disease-specific HR = 0.48 CI = 0.40, 0.58), and radiation therapy (all-cause HR = 0.65 CI = 0.57, 0.74; disease-specific HR = 0.51 CI = 0.40, 0.65). However, we had minimal comparative information about tradeoffs between and within treatment for other patient-centered outcomes in the short and long-term.

CONCLUSION

Lack of patient-centered outcomes in comparative effectiveness research in localized PCa is a major hurdle to informed and shared decision-making. More rigorous studies that can integrate patient-centered and intermediate outcomes in addition to mortality are needed.

An audit of referral and treatment patterns of high-risk prostate cancer patients in Alberta

INTRODUCTION

We aimed to determine the impact of clinical practice guidelines (CPG) on rates of radiation oncologist (RO) referral, androgen-deprivation therapy (ADT), radiation therapy (RT), and radical prostatectomy (RP) in patients with high-risk prostate cancer (HR-PCa).

METHODS

All men >18 years, diagnosed with PCa in 2005 and 2012 were identified from the Alberta Cancer Registry. Patient age, aggregated clinical risk group (ACRG) score, Gleason score (GS), pre-treatment prostate-specific antigen (PSA), RO referral, and treatment received were extracted from electronic medical records. Logistic regression modelling was used to examine associations between RO referral rates and relevant factors.

RESULTS

HR-PCa was diagnosed in 261 of 1792 patients in 2005 and 435 of 2148 in 2012. Median age and ACRG scores were similar in both years (p>0.05). The rate of patients with PSA >20 were 67% and 57% in 2005 and 2012, respectively (p=0.004). GS ≤6 was found in 13% vs. 5% of patients, GS 7 in 27% vs. 24%, and GS ≥8 in 59% vs. 71% in 2005 and 2012, respectively (p<0.001). In 2005, RO referral rate was 68% compared to 56% in 2012 (p=0.001), use of RT + ADT was 53% compared to 32% (p<0.001), and RP rate was 9% vs. 17% (p=0.002). On regression analysis, older age, 2012 year of diagnosis and higher PSA were associated with decreased RO referral rates (odds ratios [OR] 0.49, 95% confidence interval [CI] 0.39-0.61; OR 0.51, 95% CI 0.34-0.76; and OR 0.64, 95% CI 0.39-0.61), respectively [p<0.001]).

CONCLUSIONS

Since CPG creation in 2005, RO referral rates and ADT + RT use declined and RP rates increased, which demonstrates a need to improve adherence to CPG in the HR-PCa population.

Prostate Cancer Radiation Therapy: What Do Clinicians Have to Know?

Radiotherapy (RT) for prostate cancer (PC) has steadily evolved over the last decades, with improving biochemical disease-free survival. Recently population based research also revealed an association between overall survival and doses ≥ 75.6 Gray (Gy) in men with intermediate- and high-risk PC. Examples of improved RT techniques are image-guided RT, intensity-modulated RT, volumetric modulated arc therapy, and stereotactic ablative body RT, which could facilitate further dose escalation. Brachytherapy is an internal form of RT that also developed substantially. New devices such as rectum spacers and balloons have been developed to spare rectal structures. Newer techniques like protons and carbon ions have the intrinsic characteristics maximising the dose on the tumour while minimising the effect on the surrounding healthy tissue, but clinical data are needed for confirmation in randomised phase III trials. Furthermore, it provides an overview of an important discussion issue in PC treatment between urologists and radiation oncologists: the comparison between radical prostatectomy and RT. Current literature reveals that all possible treatment modalities have the same cure rate, but a different toxicity pattern. We recommend proposing the possible different treatment modalities with their own advantages and side-effects to the individual patient. Clinicians and patients should make treatment decisions together (shared decision-making) while using patient decision aids.

Effect of Preoperative Risk Group Stratification on Oncologic Outcomes of Patients with Adverse Pathologic Findings at Radical Prostatectomy

Background

Current National Comprehensive Cancer Network guidelines recommend postoperative radiation therapy based only on adverse pathologic findings (APFs), irrespective of preoperative risk group. We assessed whether a model incorporating both the preoperative risk group and APFs could predict long-term oncologic outcomes better than a model based on APFs alone.

Methods

We retrospectively reviewed 4,404 men who underwent radical prostatectomy (RP) at our institution between 1992 and 2014. After excluding patients receiving neoadjuvant therapy or with incomplete pathological or follow-up data, 3,092 men were included in the final analysis. APFs were defined as extraprostatic extension (EPE), seminal vesicle invasion (SVI), or a positive surgical margin (PSM). The adequacy of model fit to the data was compared using the likelihood-ratio test between the models with and without risk groups, and model discrimination was compared with the concordance index (c-index) for predicting biochemical recurrence (BCR) and prostate cancer-specific mortality (PCSM). We performed multivariate Cox proportional hazard model and competing risk regression analyses to identify predictors of BCR and PCSM in the total patient group and each of the risk groups.

Results

Adding risk groups to the model containing only APFs significantly improved the fit to the data (likelihood-ratio test, p <0.001) and the c-index increased from 0.693 to 0.732 for BCR and from 0.707 to 0.747 for PCSM. A RP Gleason score (GS) ≥8 and a PSM were independently associated with BCR in the total patient group and also each risk group. However, only a GS ≥8 and SVI were associated with PCSM in the total patient group (GS ≥8: hazard ratio [HR] 5.39 and SVI: HR 3.36) and the high-risk group (GS ≥8: HR 6.31 and SVI: HR 4.05).

Conclusion

The postoperative estimation of oncologic outcomes in men with APFs at RP was improved by considering preoperative risk group stratification. Although a PSM was an independent predictor for BCR, only a RP GS ≥8 and SVI were associated with PCSM in the total patient and high-risk groups.

Surgery Versus Radiotherapy for Clinically-localized Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

To date, there is no Level 1 evidence comparing the efficacy of radical prostatectomy and radiotherapy for patients with clinically-localized prostate cancer.

OBJECTIVE

To conduct a meta-analysis assessing the overall and prostate cancer-specific mortality among patients treated with radical prostatectomy or radiotherapy for clinically-localized prostate cancer.

EVIDENCE ACQUISITION

We searched Medline, EMBASE, and the Cochrane Library through June 2015 without year or language restriction, supplemented with hand search, using Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. We used multivariable adjusted hazard ratios (aHRs) to assess each endpoint. Risk of bias was assessed using the Newcastle-Ottawa scale.

EVIDENCE SYNTHESIS

Nineteen studies of low to moderate risk of bias were selected and up to 118 830 patients were pooled. Inclusion criteria and follow-up length varied between studies. Most studies assessed patients treated with external beam radiotherapy, although some included those treated with brachytherapy separately or with the external beam radiation therapy group. The risk of overall (10 studies, aHR 1.63, 95% confidence interval 1.54-1.73, p<0.00001; I(2)=0%) and prostate cancer-specific (15 studies, aHR 2.08, 95% confidence interval 1.76-2.47, p < 0.00001; I(2)=48%) mortality were higher for patients treated with radiotherapy compared with those treated with surgery. Subgroup analyses by risk group, radiation regimen, time period, and follow-up length did not alter the direction of results.

CONCLUSIONS

Radiotherapy for prostate cancer is associated with an increased risk of overall and prostate cancer-specific mortality compared with surgery based on observational data with low to moderate risk of bias. These data, combined with the forthcoming randomized data, may aid clinical decision making.

PATIENT SUMMARY

We reviewed available studies assessing mortality after prostate cancer treatment with surgery or radiotherapy. While the studies used have a potential for bias due to their observational design, we demonstrated consistently higher mortality for patients treated with radiotherapy rather than surgery.

Age-adjusted Charlson comorbidity index is a significant prognostic factor for long-term survival of patients with high-risk prostate cancer after radical prostatectomy: a Bayesian model averaging approach

PURPOSE

We investigated the long-term prognostic impact of age-adjusted Charlson comorbidity index (ACCI) on overall mortality (OM), cancer-specific mortality (CSM), and other-cause mortality (OCM) according to risk stratification in patients with prostate cancer who underwent radical prostatectomy.

METHODS

Data from 542 patients who underwent radical prostatectomy between 1992 and 2006 were analyzed. The impact of preoperative variables including age, prostate-specific antigen, biopsy Gleason sum, clinical stage, and ACCI on OM, CSM, and OCM were analyzed according to risk groups, with a median follow-up of 101 months.

RESULTS

Subjects were stratified into either the high-risk group (n = 241) or the non-high-risk group (n = 301). Cox proportional hazards model demonstrated that the ACCI was the only significant predictor for OM in all patients (hazard ratio, HR 1.41; 95 % confidence interval, CI 1.19-1.66), non-high-risk group (HR 1.45; 95 % CI 1.09-1.91), and high-risk group (HR 1.37; 95 % CI 1.11-1.69). In competing risk analysis, CSM was not associated with the ACCI in either risk group. However, the ACCI had a significant impact on OCM in both the non-high-risk (HR 1.55; 95 % CI 1.16-2.1) and high-risk groups (HR 1.60; 95 % CI 1.23-2.08). A Bayesian model averaging approach verified that the ACCI was the most powerful predictor for OM and OCM in the both high-risk and non-high-risk groups.

CONCLUSIONS

A thorough assessment of comorbidities is mandatory in establishing prognoses, even when considering invasive treatment modalities in high-risk prostate cancer patients.

Comparison of biochemical recurrence in prostate cancer patients treated with radical prostatectomy or radiotherapy

Purpose

We evaluated the biochemical recurrence (BCR) of prostate cancer patients treated by radical prostatectomy (RP) or radiotherapy (RT).

Materials and Methods

Patients who underwent RP or RT as primary definitive treatment from 2007 were enrolled for this study. They were divided into two groups; the low-intermediate risk group and the high risk group according to the National Comprehensive Cancer Network guidelines. We compared differences such as age, prostate specific antigen, Gleason score, follow-up duration, clinical T staging, and BCR. Their BCR-free survival rates were analyzed.

Results

A total of 165 patients were enrolled. There were 115 patients in the low-intermediate risk. Among them, 88 received RP and 27 underwent RT. BCR occurred in 9 of the RP patients (10.2%) and 3 of the RT patients (11.1%). For the high risk group, 50 patients were included. RP was performed in 25 patients and RT in 25 patients. BCR was observed in 4 of the RP patients (16%) and 12 of the RT patients (48%). There were no differences in BCR-free survival for the low-intermediate group (p=0.765). For the high risk group, the RP group had a higher BCR free survival rate (p=0.032).

Conclusions

No difference of BCR and BCR-free survival was seen in the low-intermediate risk group but lower BCR and better BCR-free survival were observed for patients that received RP in the high risk group. RP should be a more strongly considered option when deciding the treatment method for selected high risk patients.

Urologic cancers in Korea

The incidence and prevalence of prostate and kidney cancers have been increasing in Korea during the last decade, and a marked improvement in survival rates has been noted. With a substantial proportion of the cancers diagnosed at an earlier stage of the disease, the landscape of urologic cancer treatment in Korea has been characterized by an exponential increase in the number of patients receiving surgical treatment. Throughout the last decade, an increasing proportion of surgeries have been performed using minimally invasive methods, with a notable increase in robot-assisted surgery.The evaluation and management strategies of urologic cancer in Korea are primarily based on an existing evidence-based framework provided by international guidelines. The adoption and clinical application of novel surgical techniques and systemic agents targeted at advanced stage cancer are promptly adopted; accordingly, multidisciplinary treatment options are often available for various cancers at different stages. At the same time, treatment decisions are greatly influenced by the availability of healthcare resources, which may be limited due to the National Health Insurance reimbursement policy.A racial disparity in cancer features appears to exist for certain urologic cancers among Korean patients, and the optimal management strategy specific for the Korean population has yet to be confirmed. A national comprehensive cancer database is needed for better insight into risk factors, selection of sequential strategies, tumor biology and survival outcome of Korean urologic cancer patients.

Systematic review and meta-analysis of the survival outcomes of first-line treatment options in high-risk prostate cancer

Prostate cancer (PCa) is the most common non-dermatologic cancer in the western countries in western countries. High-risk PCa accounts for 15% of the diagnosed cases. In this study, we compare the long-term survival outcomes of radical prostatectomy (RP), radiation therapy (RT), brachytherapy (BT), androgen- deprivation therapy (ADT), and watchful waiting (WW) in high-risk prostate cancer (PCa). Overall, RP/(RT plus ADT) gave the best survival outcome in patients with high-risk PCa, whereas ADT/WW had the worst outcome. The overall priority for treatment strategy could be ranked as follows: RP/(RT plus ADT), RT, and ADT/WW. RP had significant better overall survival (OS) than RT or BT, and RP had significant lower cancer-specific mortality (CSM) than RT (0.51 [95% CI 0.30–0.73], P<0.001). ADT improved the cancer-specific survival (CSS) of RP based on a case-controlled study; added ADT to RT failed to challenge the position of RP but could improve the outcome of RT. In conclusions,RP/(RT plus adjuvant ADT) could both be used for the first-line therapy of high-risk PCa. When encountering an individual patient, urologists should consider various factors like tumors themselves, preferences of individuals, and so on.

Radiotherapy before and after radical prostatectomy for high-risk and locally advanced prostate cancer

OBJECTIVES

Men with localized high-risk prostate cancer carry significant risk of prostate cancer-specific mortality. The best treatment approach to minimize this risk is unclear. In this review, we evaluate the role of radiation before and after radical prostatectomy.

METHODS AND MATERIALS

A critical review of the literature was performed regarding the application of external radiation therapy (RT) in combination with prostatectomy for high-risk localized prostate cancer.

RESULTS

Up to 70% of men with high-risk localized disease may require adjuvant therapy because of adverse pathologic features or biochemical recurrence in the absence of systemic disease. The utility of adjuvant RT among men with adverse pathologic features are well established at least regarding minimizing biochemical recurrence risk. The optimal timing of salvage radiation is the subject of ongoing studies. Neoadjuvant RT requires further study but is a potentially attractive method because of decreased radiation field sizes and potential radiobiologic benefits of delivering RT before surgery. Salvage prostatectomy is effective at treating local recurrence after radiation but is associated with significant surgical morbidity.

CONCLUSIONS

Combining local therapies including radical prostatectomy and RT can be a reasonable approach. Care should be taken at the initial presentation of high-risk localized prostate cancer to consider and plan for the likelihood of multimodality care.

Current status of radical prostatectomy for high-risk prostate cancer

Despite the wide application of prostate-specific antigen-based screening leading to a profound stage migration in prostate cancer (PC), a significant percentage of men are still being diagnosed with clinically high-risk disease that requires aggressive treatment. Optimal management in these patients remains challenging, and strong advocates for radical prostatectomy (RP), radiotherapy, androgen deprivation therapy, and, increasingly, a multimodal approach abound. Currently, surgery for high-risk PC is frequently applied. RP offers an attractive opportunity for tumor excision either as a definitive management or as a first step in multimodal therapy. Nevertheless, this approach is still controversial. In this review, we discuss the current evidence for the role of RP in this clinical setting, including surgical considerations and outcomes. The role of robot-assisted RP, which is increasingly utilized in Korea in this clinical scenario, is discussed.