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Roach M. Pragmatic clinical trials for localized prostate cancer: lessons learned and "three sins". Front Oncol 2024; 14:1379306. [PMID: 39119086 PMCID: PMC11306871 DOI: 10.3389/fonc.2024.1379306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 07/01/2024] [Indexed: 08/10/2024] Open
Abstract
In "Explanatory and Pragmatic Attitudes in Therapeutic Trials", Schwatrz and Lelouch describe two approaches to the design of trials, "… the first "explanatory", the second "pragmatic". They explained "… the biologist may be interested to know whether the drugs differ in their effects … the explanatory approach". Biologically endpoints might determine whether it was better to give androgen deprivation therapy (ADT) before or after external beam radiation (EBRT) (i.e., does the sequence of treatments matter). Alternatively, if the arms focus on a clinical endpoint, this is considered … "the pragmatic approach". An example of a clinically relevant endpoint is overall survival (OS). A real-world example of this are the two randomized controlled trials (RCTs) evaluating the role of prophylactic whole pelvic radiotherapy (WPRT) conducted by the Radiation Therapy Oncology Group (RTOG). RTOG 9413 evaluated possible interactions between the sequence of drugs and volume irradiated, while RTOG/NRG 0924 focuses on OS. There appears to be a common pattern of "what not to do", or "design errors" made by a number of investigators, that I call the "three sins". I posit that the prospects for a well-designed pragmatic RCT are likely to be high if these "three sins" are avoided/minimized. The "three sins" alluded to are: 1. You can't prove something doesn't work by treating people who don't need the treatment. 2. You can't prove something does not work if the treatment is not done properly. 3. You can't prove something does not work with an underpowered study.
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Affiliation(s)
- Mack Roach
- Departments of Radiation Oncology and Urology, University of California, San Francisco, CA, United States
- Helen Diller Family Comprehensive Cancer Center, Medical Center, University of California, San Francisco, CA, United States
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Hekman L, Barrett A, Ross D, Palaganas E, Giridhar P, Elumalai T, V P, Block AM, Welsh JS, Harkenrider MM, Saini S, Roy S, Farooq A, Gupta G, Hsieh CE, Venkatesulu B, Solanki AA. A Systematic Review of Clinical Trials Comparing Radiation Therapy Versus Radical Prostatectomy in Prostate Cancer. Clin Genitourin Cancer 2024; 22:102157. [PMID: 39084158 DOI: 10.1016/j.clgc.2024.102157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/03/2024] [Accepted: 07/04/2024] [Indexed: 08/02/2024]
Abstract
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.
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Affiliation(s)
- Lauren Hekman
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL.
| | - Athena Barrett
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Dylan Ross
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Eli Palaganas
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Prashanth Giridhar
- Department of Radiation Oncology and Urology, Tata Memorial Center, Varanasi, Uttar Pradesh, India
| | - Thiraviyam Elumalai
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Pragathee V
- Department of Medicine, Karpagam Faculty of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Alec M Block
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL; Edward Hines Veteran Affairs Hospital, Chicago, IL
| | - James S Welsh
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL; Edward Hines Veteran Affairs Hospital, Chicago, IL
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Sashank Saini
- Department of Radiation Oncology and Urology, Tata Memorial Center, Varanasi, Uttar Pradesh, India
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush Medical Center, Chicago, IL
| | - Ahmer Farooq
- Department of Urology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Loyola University Medical Center, Maywood, IL
| | - Gopal Gupta
- Department of Urology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Loyola University Medical Center, Maywood, IL
| | - Cheng En Hsieh
- Department of Radiation Oncology, Institute for Radiological Research, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taoyuan City, Taiwan
| | - BhanuPrasad Venkatesulu
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL; Edward Hines Veteran Affairs Hospital, Chicago, IL
| | - Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL; Edward Hines Veteran Affairs Hospital, Chicago, IL
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Heesterman BL, Aben KKH, de Jong IJ, Pos FJ, van der Hel OL. Radical prostatectomy versus external beam radiotherapy with androgen deprivation therapy for high-risk prostate cancer: a systematic review. BMC Cancer 2023; 23:398. [PMID: 37142955 PMCID: PMC10157926 DOI: 10.1186/s12885-023-10842-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/13/2023] [Indexed: 05/06/2023] Open
Abstract
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.
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Affiliation(s)
- Berdine L Heesterman
- Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, 3511 DT, Utrecht, The Netherlands
| | - Katja K H Aben
- Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, 3511 DT, Utrecht, The Netherlands.
- Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Igle Jan de Jong
- Department of Urology, University Medical Center Groningen, Groningen, the Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Olga L van der Hel
- Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, 3511 DT, Utrecht, The Netherlands
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Kowalchuk RO, Kim H, Harmsen WS, Jeans EB, Morris LK, Mullikin TC, Miller RC, Wong WW, Vargas CE, Trifiletti DM, Phillips RM, Choo CR, Davis BJ, Beriwal S, Tendulkar RD, Stish BJ, Breen WG, Waddle MR. Cost effectiveness of treatment strategies for high risk prostate cancer. Cancer 2022; 128:3815-3823. [PMID: 36070558 DOI: 10.1002/cncr.34450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients with high-risk prostate cancer (HRPC) have multiple accepted treatment options. Because there is no overall survival benefit of one option over another, appropriate treatment must consider patient life expectancy, quality of life, and cost. METHODS The authors compared quality-adjusted life years (QALYs) and cost effectiveness among treatment options for HRPC using a Markov model with three treatment arms: (1) external-beam radiotherapy (EBRT) delivered with 20 fractions, (2) EBRT with 23 fractions followed by low-dose-rate (LDR) brachytherapy boost, or (3) radical prostatectomy alone. An exploratory analysis considered a simultaneous integrated boost according to the FLAME trial (ClinicalTrials.gov identifier NCT01168479). RESULTS Treatment strategies were compared using the incremental cost-effectiveness ratio (ICER). EBRT with LDR brachytherapy boost was a cost-effective strategy (ICER, $20,929 per QALY gained). These results were most sensitive to variations in the biochemical failure rate. However, the results still demonstrated cost effectiveness for the brachytherapy boost paradigm, regardless of any tested parameter ranges. Probabilistic sensitivity analysis demonstrated that EBRT with LDR brachytherapy was favored in 52% of 100,000 Monte Carlo iterations. In an exploratory analysis, EBRT with a simultaneous integrated boost was also a cost-effective strategy, resulting in an ICER of $62,607 per QALY gained; however, it was not cost effective compared with EBRT plus LDR brachytherapy boost. CONCLUSIONS EBRT with LDR brachytherapy boost may be a cost-effective treatment strategy compared with EBRT alone and radical prostatectomy for HRPC, demonstrating high-value care. The current analysis suggests that a reduction in biochemical failure alone can result in cost-effective care, despite no change in overall survival.
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Affiliation(s)
- Roman O Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hayeon Kim
- Department of Radiation Oncology, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Elizabeth B Jeans
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsay K Morris
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert C Miller
- Mayo Clinic, Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Daniel M Trifiletti
- Mayo Clinic, Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan M Phillips
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - C R Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sushil Beriwal
- Allegheny Health Networks, Pittsburgh, Pennsylvania, USA.,Medical Affairs, Varian Medical Systems, Pittsburgh, Pennsylvania, USA
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Li SW, Chiu AW, Huang AC, Lai YW, Leu JD, Hsiao YC, Chen SS, Hsueh TY. Ten-years outcome analysis in patients with clinically localized prostate cancer treated by radical prostatectomy or external beam radiation therapy. Front Surg 2022; 9:966025. [PMID: 35965869 PMCID: PMC9372291 DOI: 10.3389/fsurg.2022.966025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/14/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Since there was no consensus on treatment options for localized prostate cancer, we performed a retrospective study to compare the long-term survival benefit of radiotherapy (RT) versus laparoscopic radical prostatectomy (LRP) in Taiwan. Methods 218 patients with clinically localized prostate cancer treated between 2008 and 2017 (64 with LRP and 154 with RT) were enrolled in this study. The outcomes of RT and LRP were assessed after patients were stratified according to Gleason score, stage, and risk group. Crude survival, prostate cancer-specific survival, and metastasis-free survival were evaluated using the log-rank test. Results The 5-year crude survival rate was 93.3% in the LRP group and 59.3% in the RT group. A significant survival benefit was found in the LRP group compared with the RT group (p = 0.004). Furthermore, significant differences were found in disease-specific survival (93.3% vs. 64.7%, p = 0.022) and metastasis-free survival (48% vs. 40.2%, p = 0.045) between the LRP and RT groups. Conclusions Men with localized prostate cancer treated initially with LRP had a lower risk of prostate cancer-specific death and metastases compared with those treated with RT.
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Affiliation(s)
- Shu-Wen Li
- Division of Urology, Department of Surgery, Taipei City Hospital renai Branch, Taipei, Taiwan
| | - Allen W. Chiu
- Division of Urology, Department of Surgery, Taipei City Hospital renai Branch, Taipei, Taiwan
- Department of Urology, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Urology, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Andy C. Huang
- Division of Urology, Department of Surgery, Taipei City Hospital renai Branch, Taipei, Taiwan
- Department of Urology, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Yu-Wei Lai
- Division of Urology, Department of Surgery, Taipei City Hospital renai Branch, Taipei, Taiwan
- Department of Urology, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Jyh-Der Leu
- Division of Radiation Oncology, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Yi-Chun Hsiao
- Division of Urology, Department of Surgery, Taipei City Hospital renai Branch, Taipei, Taiwan
| | - Shiou-Sheng Chen
- Department of Urology, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Urology, Department of Surgery, Taipei City Hospital Zhongxiao Branch, Taipei, Taiwan
| | - Thomas Y. Hsueh
- Division of Urology, Department of Surgery, Taipei City Hospital renai Branch, Taipei, Taiwan
- Department of Urology, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Correspondence: Thomas Y. Hsueh
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Patient reported outcomes and health related quality of life in localized prostate cancer: A review of current evidence. Urol Oncol 2022; 40:304-314. [DOI: 10.1016/j.urolonc.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/30/2022] [Accepted: 04/13/2022] [Indexed: 11/21/2022]
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Relative Incidence of Emergency Department Visits After Treatment for Prostate Cancer with Radiation Therapy or Radical Prostatectomy. Pract Radiat Oncol 2022; 12:e415-e422. [PMID: 35595216 DOI: 10.1016/j.prro.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/12/2022] [Accepted: 05/03/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Side effect profiles play an important role in treatment decisions for localized prostate cancer. Emergency department (ED) visits, which may be due to side effects from treatment, can be measured in real-world, structured, electronic health record (EHR) data. The goal of this study was to determine whether treatments for localized prostate cancer are associated with ED visits, as a measure of side effects, using EHR data. METHODS AND MATERIALS We used a self-controlled case series study (SCCS) design, including patients treated at an urban academic medical center with radiation therapy (RT) or radical prostatectomy (RP) for prostate cancer between 2011 and 2020 who had visits documented for ≥ 6 months before and after treatment and ≥1 ED visit. We estimated relative incidences (RI) of ED visits, comparing incidence in the exposed and unexposed periods, with the exposed period being between start of treatment and 1 month after completion, and the unexposed period consisting of all other documented time. RESULTS Among men who had at least one ED visit and after adjusting for age, there were higher rates of ED visits after RP (RI 20.4, 95% confidence interval [CI] 15.4-27.0, p<0.001), RT overall (RI 2.4, CI 1.7-3.4, p<0.001), intensity modulated radiation therapy with high dose-rate brachytherapy (HDR) (RI 3.4, CI 1.7-6.8, p<0.001) or stereotactic body radiation therapy boost (RI 7.1, CI 3.4-14.8, p < 0.001), and HDR alone (RI 16.3, CI 7.2-36.9, p<0.001), compared to unexposed time. The number needed to harm to result in an ED visit was less for RP (17, CI 13-23) than RT overall (43, CI 25-126), but varied by RT modality. CONCLUSIONS In summary, relative rates of ED visits vary by treatment type, suggesting differing severities of side effects. These data may aid in selecting treatments and demonstrate the feasibility of using the SCCS study design on ED visits in real-world, structured EHR data to better understand side effects of treatment.
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Wu SY, Huy LD, Liao CJ, Huang CC. Acute, Subchronic, and Chronic Complications of Radical Prostatectomy Versus Radiotherapy With Hormone Therapy in Older Adults With High-Risk Prostate Adenocarcinoma. Front Oncol 2022; 12:875036. [PMID: 35586485 PMCID: PMC9108927 DOI: 10.3389/fonc.2022.875036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/11/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose To compare acute, subchronic, and chronic complications between older patients with high-risk localized prostate cancer (HR-LPC) receiving radical prostatectomy (RP) and high-dose intensity-modulated radiotherapy (IMRT) combined with long-term hormone therapy (HT). Patients and Methods We recruited older patients (≥80 years) with HR-LPC from the Taiwan Cancer Registry database. After propensity score matching, logistic regression analysis was used to compare the acute, subchronic, and chronic complication rates between patients who underwent RP (the RP group) and high-dose IMRT combined with long-term HT (the IMRT+HT group). Results Benign prostatic hyperplasia (BPH) symptoms and urinary incontinence (UI) were the most common complications over 5 years (BPH symptoms: RP, 17.69%; IMRT+HT, 29.58%; UI: RP, 10.47%; IMRT+HT, 5.50%). Compared with the RP group, the IMRT+HT group had higher odds of BPH symptoms and lower odds of UI and hernia after the 5-year follow-up period. The impotence rates were significantly higher in the IMRT+HT group than in the RP group at 3 months and 1 year after treatment and became nonsignificant after 2 years. At 5 years after treatment, the IMRT+HT group had lower risks of UI (adjusted odds ratio [aOR], 0.50; 95% confidence interval [CI], 0.28–0.88) and hernia (aOR, 0.21; 95% CI, 0.11–0.82) and a higher risk of BPH symptoms (aOR, 4.15; 95% CI, 2.82–7.37) than the RP group. Conclusion IMRT+HT was associated with lower UI and hernia risks than RP. By contrast, RP was associated with fewer complications of BPH over the follow-up period and less impotence during the first year after treatment. Our findings provide important and valuable references for shared decision-making for optimal therapy selection among older men with HR-LPC.
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Affiliation(s)
- Szu-Yuan Wu
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan
- Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Cancer Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan
- Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Le Duc Huy
- Master Program in School of Health Care Administration, Department of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
- Health Management Training Institute, University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Chih Jung Liao
- Department of Medical Imaging, Taipei Medical University-Shuang-ho Hospital, New Taipei City, Taiwan
| | - Chung-Chien Huang
- International PhD Program in Biotech and Healthcare Management, School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
- Department of Medical Quality, Taipei Municipal Wan Fang Hospital - Managed by Taipei Medical University, Taipei, Taiwan
- Department of Long-Term Care and School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department and School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
- *Correspondence: Chung-Chien Huang,
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Kishan AU, Karnes RJ, Romero T, Wong JK, Motterle G, Tosoian JJ, Trock BJ, Klein EA, Stish BJ, Dess RT, Spratt DE, Pilar A, Reddy C, Levin-Epstein R, Wedde TB, Lilleby WA, Fiano R, Merrick GS, Stock RG, Demanes DJ, Moran BJ, Braccioforte M, Huland H, Tran PT, Martin S, Martínez-Monge R, Krauss DJ, Abu-Isa EI, Alam R, Schwen Z, Chang AJ, Pisansky TM, Choo R, Song DY, Greco S, Deville C, McNutt T, DeWeese TL, Ross AE, Ciezki JP, Boutros PC, Nickols NG, Bhat P, Shabsovich D, Juarez JE, Chong N, Kupelian PA, D’Amico AV, Rettig MB, Berlin A, Tward JD, Davis BJ, Reiter RE, Steinberg ML, Elashoff D, Horwitz EM, Tendulkar RD, Tilki D. Comparison of Multimodal Therapies and Outcomes Among Patients With High-Risk Prostate Cancer With Adverse Clinicopathologic Features. JAMA Netw Open 2021; 4:e2115312. [PMID: 34196715 PMCID: PMC8251338 DOI: 10.1001/jamanetworkopen.2021.15312] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE The optimal management strategy for high-risk prostate cancer and additional adverse clinicopathologic features remains unknown. OBJECTIVE To compare clinical outcomes among patients with high-risk prostate cancer after definitive treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients with high-risk prostate cancer (as defined by the National Comprehensive Cancer Network [NCCN]) and at least 1 adverse clinicopathologic feature (defined as any primary Gleason pattern 5 on biopsy, clinical T3b-4 disease, ≥50% cores with biopsy results positive for prostate cancer, or NCCN ≥2 high-risk features) treated between 2000 and 2014 at 16 tertiary centers. Data were analyzed in November 2020. EXPOSURES Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy boost (BT) with ADT. Guideline-concordant multimodal treatment was defined as RP with appropriate use of multimodal therapy (optimal RP), EBRT with at least 2 years of ADT (optimal EBRT), or EBRT with BT with at least 1 year ADT (optimal EBRT with BT). MAIN OUTCOMES AND MEASURES The primary outcome was prostate cancer-specific mortality; distant metastasis was a secondary outcome. Differences were evaluated using inverse probability of treatment weight-adjusted Fine-Gray competing risk regression models. RESULTS A total of 6004 men (median [interquartile range] age, 66.4 [60.9-71.8] years) with high-risk prostate cancer were analyzed, including 3175 patients (52.9%) who underwent RP, 1830 patients (30.5%) who underwent EBRT alone, and 999 patients (16.6%) who underwent EBRT with BT. Compared with RP, treatment with EBRT with BT (subdistribution hazard ratio [sHR] 0.78, [95% CI, 0.63-0.97]; P = .03) or with EBRT alone (sHR, 0.70 [95% CI, 0.53-0.92]; P = .01) was associated with significantly improved prostate cancer-specific mortality; there was no difference in prostate cancer-specific mortality between EBRT with BT and EBRT alone (sHR, 0.89 [95% CI, 0.67-1.18]; P = .43). No significant differences in prostate cancer-specific mortality were found across treatment cohorts among 2940 patients who received guideline-concordant multimodality treatment (eg, optimal EBRT alone vs optimal RP: sHR, 0.76 [95% CI, 0.52-1.09]; P = .14). However, treatment with EBRT alone or EBRT with BT was consistently associated with lower rates of distant metastasis compared with treatment with RP (eg, EBRT vs RP: sHR, 0.50 [95% CI, 0.44-0.58]; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that among patients with high-risk prostate cancer and additional unfavorable clinicopathologic features receiving guideline-concordant multimodal therapy, prostate cancer-specific mortality outcomes were equivalent among those treated with RP, EBRT, and EBRT with BT, although distant metastasis outcomes were more favorable among patients treated with EBRT and EBRT with BT. Optimal multimodality treatment is critical for improving outcomes in patients with high-risk prostate cancer.
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Affiliation(s)
- Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles
- Department of Urology, University of California, Los Angeles
| | | | - Tahmineh Romero
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Jessica K. Wong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | | | | | - Bruce J. Trock
- Department of Urology, Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland
| | - Eric A. Klein
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley J. Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Robert T. Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Avinash Pilar
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chandana Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Trude B. Wedde
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Wolfgang A. Lilleby
- Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - Ryan Fiano
- Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
| | - Gregory S. Merrick
- Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
| | - Richard G. Stock
- Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Brian J. Moran
- Prostate Cancer Foundation of Chicago, Westmont, Illinois
| | | | - Hartwig Huland
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Phuoc T. Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Santiago Martin
- Department of Oncology, Clínica Universitaria de Navarra, University of Navarra, Pamplona, Spain
| | | | - Daniel J. Krauss
- William Beaumont School of Medicine, Oakland University, Royal Oak, Michigan
| | - Eyad I. Abu-Isa
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Ridwan Alam
- Department of Urology, Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland
| | - Zeyad Schwen
- Department of Urology, Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland
| | - Albert J. Chang
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Richard Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Daniel Y. Song
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen Greco
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Theodore L. DeWeese
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ashley E. Ross
- Texas Oncology, Dallas
- Now with Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jay P. Ciezki
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul C. Boutros
- Department of Urology, University of California, Los Angeles
- Department of Human Genetics, University of California, Los Angeles
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California, Los Angeles
- Department of Radiation Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Prashant Bhat
- Department of Radiation Oncology, University of California, Los Angeles
| | - David Shabsovich
- Department of Radiation Oncology, University of California, Los Angeles
| | - Jesus E. Juarez
- Department of Radiation Oncology, University of California, Los Angeles
| | - Natalie Chong
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Anthony V. D’Amico
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Matthew B. Rettig
- Division of Hematology and Oncology, Department of Medicine, University of California, Los Angeles
- Department of Hematology and Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jonathan D. Tward
- Department of Radiation Oncology, Huntsman Cancer Institute, The University of Utah, Salt Lake City
| | - Brian J. Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - David Elashoff
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles
| | - Eric M. Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Rahul D. Tendulkar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
- Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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10
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van Son MJ, Peters M, Reddy D, Shah TT, Hosking-Jervis F, Robinson S, Lagendijk JJW, Mangar S, Dudderidge T, McCracken S, Hindley RG, Emara A, Nigam R, Persad R, Virdi J, Lewi H, Moore C, Orczyk C, Emberton M, Arya M, Ahmed HU, van der Voort van Zyp JRN, Winkler M, Falconer A. Conventional radical versus focal treatment for localised prostate cancer: a propensity score weighted comparison of 6-year tumour control. Prostate Cancer Prostatic Dis 2021; 24:1120-1128. [PMID: 33934114 DOI: 10.1038/s41391-021-00369-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/14/2021] [Accepted: 04/15/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND For localised prostate cancer, focal therapy offers an organ-sparing alternative to radical treatments (radiotherapy or prostatectomy). Currently, there is no randomised comparative effectiveness data evaluating cancer control of both strategies. METHODS Following the eligibility criteria PSA < 20 ng/mL, Gleason score ≤ 7 and T-stage ≤ T2c, we included 830 radical (440 radiotherapy, 390 prostatectomy) and 530 focal therapy (cryotherapy, high-intensity focused ultrasound or high-dose-rate brachytherapy) patients treated between 2005 and 2018 from multicentre registries in the Netherlands and the UK. A propensity score weighted (PSW) analysis was performed to compare failure-free survival (FFS), with failure defined as salvage treatment, metastatic disease, systemic treatment (androgen deprivation therapy or chemotherapy), or progression to watchful waiting. The secondary outcome was overall survival (OS). Median (IQR) follow-up in each cohort was 55 (28-83) and 62 (42-83) months, respectively. RESULTS At baseline, radical patients had higher PSA (10.3 versus 7.9) and higher-grade disease (31% ISUP 3 versus 11%) compared to focal patients. After PSW, all covariates were balanced (SMD < 0.1). 6-year weighted FFS was higher after radical therapy (80.3%, 95% CI 73.9-87.3) than after focal therapy (72.8%, 95% CI 66.8-79.8) although not statistically significant (p = 0.1). 6-year weighted OS was significantly lower after radical therapy (93.4%, 95% CI 90.1-95.2 versus 97.5%, 95% CI 94-99.9; p = 0.02). When compared in a three-way analysis, focal and LRP patients had a higher risk of treatment failure than EBRT patients (p < 0.001), but EBRT patients had a higher risk of mortality than focal patients (p = 0.008). CONCLUSIONS Within the limitations of a cohort-based analysis in which residual confounders are likely to exist, we found no clinically relevant difference in cancer control conferred by focal therapy compared to radical therapy at 6 years.
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Affiliation(s)
- Marieke J van Son
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK. .,Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK. .,Department of Radiotherapy, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Max Peters
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Deepika Reddy
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Urology, Sunderland Royal Hospital, City Hospital Foundation Trust, Sunderland, UK
| | - Feargus Hosking-Jervis
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Stephen Robinson
- Division of Clinical Oncology, Department of Radiotherapy, Charing Cross Hospital, Imperial College London Healthcare NHS Trust, London, UK
| | - Jan J W Lagendijk
- Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen Mangar
- Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Stuart McCracken
- Department of Urology, Sunderland Royal Hospital, City Hospital Foundation Trust, Sunderland, UK
| | - Richard G Hindley
- Department of Urology, Hampshire Hospitals & Ain Shams University Hospitals, Basingstoke, UK
| | - Amr Emara
- Department of Urology, Hampshire Hospitals & Ain Shams University Hospitals, Basingstoke, UK
| | - Raj Nigam
- BMI Mount Alvernia Hospital, Guildford, Surrey, UK
| | - Raj Persad
- Department of Urology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jaspal Virdi
- Department of Urology, Princes Alexandra Hospital NHS Trust, Harlow, UK.,Rivers Hospital, Essex, UK
| | | | - Caroline Moore
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Mark Emberton
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Manit Arya
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK.,Department of Urology, Princes Alexandra Hospital NHS Trust, Harlow, UK.,Rivers Hospital, Essex, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Matt Winkler
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Alison Falconer
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
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11
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An audit of high dose-rate prostate brachytherapy treatment planning at six Swedish clinics. J Contemp Brachytherapy 2021; 13:59-71. [PMID: 34025738 PMCID: PMC8117718 DOI: 10.5114/jcb.2021.103588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/05/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose High dose-rate prostate brachytherapy has been implemented in Sweden in the late 1980s and early 1990s in six clinics using the same schedule: 20 Gy in two fractions combined with 50 Gy in 25 fractions with external beam radiation therapy. Thirty years have passed and during these years, various aspects of the treatment process have developed, such as ultrasound-guided imaging and treatment planning system. An audit was conducted, including a questionnaire and treatment planning, which aimed to gather knowledge about treatment planning methods in Swedish clinics. Material and methods A questionnaire and a treatment planning case (non-anatomical images) were sent to six Swedish clinics, in which high-dose-rate prostate brachytherapy is performed. Treatment plans were compared using dosimetric indices and equivalent 2 Gy doses (EQD2). Treatment planning system report was used to compare dwell positions and dwell times. Results For all the clinics, the planning aim for the target was 10.0 Gy, but the volume to receive the dose differed from 95% to 100%. Dose constraints for organs at risk varied with up to 2 Gy. The dose to 90% of target volume ranged from 10.0 Gy to 11.1 Gy, equivalent to 26.0 Gy EQD2 and 31.3 Gy EQD2, respectively. Dose non-homogeneity ratio differed from 0.18 to 0.32 for clinical target volume (CTV) in treatment plans and conformity index ranged from 0.52 to 0.59 for CTV. Conclusions Dose constraints for the organs at risk are showing a larger variation than that reflected in compared treatments plans. In all treatment plans in our audit, at least 10 Gy was administered giving a total treatment of 102 Gy EQD2, which is in the upper part of the prescription doses published in the GEC/ESTRO recommendations.
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12
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Taylor JM, Chen VE, Miller RC, Greenberger BA. The Impact of Prostate Cancer Treatment on Quality of Life: A Narrative Review with a Focus on Randomized Data. Res Rep Urol 2020; 12:533-546. [PMID: 33150144 PMCID: PMC7605665 DOI: 10.2147/rru.s243088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/06/2020] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- James M Taylor
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA, USA
| | - Victor E Chen
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan C Miller
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin A Greenberger
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA, USA
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13
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Taguchi S, Shiraishi K, Fukuhara H. Updated evidence on oncological outcomes of surgery versus external beam radiotherapy for localized prostate cancer. Jpn J Clin Oncol 2020; 50:963-969. [PMID: 32580211 DOI: 10.1093/jjco/hyaa105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/31/2020] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Satoru Taguchi
- Department of Urology, Kyorin University School of Medicine, Tokyo, Japan
| | - Kenshiro Shiraishi
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroshi Fukuhara
- Department of Urology, Kyorin University School of Medicine, Tokyo, Japan
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14
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Houédé N, Rébillard X, Bouvet S, Kabani S, Fabbro-Peray P, Trétarre B, Ménégaux F. Impact on quality of life 3 years after diagnosis of prostate cancer patients below 75 at diagnosis: an observational case-control study. BMC Cancer 2020; 20:757. [PMID: 32787797 PMCID: PMC7424648 DOI: 10.1186/s12885-020-07244-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prostate cancer patients are known to suffer from poor sexual and urinary long-term side-effects following treatment, potentially impacting quality of life. The purpose of our study was to compare health-related quality of life at 3 years between prostate cancer patients and healthy controls according to key life-style characteristics. Secondary objectives were to compare urological dysfunction, sexual function, anxiety and depression. METHODS Multicentric, case-control, observational prospective, open, follow-up study including 819 prostate cancer patients < 75 years old from the EPICAP cohort, newly diagnosed from 1 December 2011 to 31 March 2014 and 879 healthy controls. Participants were excluded if they experienced a relapse. Controls from the same geographical region were age-matched and were excluded if they were diagnosed with prostate cancer. Patients received one of the following treatments: active surveillance (AS), radical prostatectomy (RP), external beam radiotherapy (EBRT), High-intensity Focused Ultrasound (HIFU), chemotherapy (CT), or androgen deprivation therapy (ADT) as appropriate. The primary outcome was the quality of life as evaluated by the QLQ-C30 questionnaire. Scores were analyzed by multivariate analysis to adjust for predefined socio-demographic confounding effects. RESULTS In total, 564 participants were included (mean age 67.9 years): 376 patients and 188 controls. Treatment breakdown was: 258 underwent RP, 90 received EBRT, 52 brachytherapy or HIFU, 15 CT, 26 ADT and 61 AS. There was no difference in median global quality of life between patients and controls (94.87 vs 94.15, p = 0.71). Multivariate analysis showed poorer social functioning in patients (24.3% vs. 16.3%, p = 0.0209), more dyspnea (22% vs. 12.4%, p = 0.0078), and yet less current pain (23% vs 33%, p = 0.0151). CONCLUSIONS Global health status score at 3 years after diagnosis was similar between patients and controls, though patients showed a significantly worse social functioning. Prostate cancer diagnosis per se does not seem to impact the quality of life of patients < 75 years at diagnosis. However, the therapeutic option that will be chosen following diagnosis should be carefully discussed with the medical staff in terms of benefit-risk ratios as it could have a long-term impact on urinary or erectile dysfunction. TRIAL REGISTRATION clinicaltrials.gov, NCT02854982 . Registered 4 August 2016, retrospectively registered.
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Affiliation(s)
- Nadine Houédé
- Institut de Cancérologie du Gard, CHU Nîmes, Rue du Pr Henri Pujol, 30029, Nîmes Cedex 9, France. .,INSERM U1194, Montpellier Cancer Research Institute & Université de Montpellier, Montpellier, France.
| | | | - Sophie Bouvet
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology, (BESPIM), CHU Nîmes, Nîmes, France
| | - Sarah Kabani
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology, (BESPIM), CHU Nîmes, Nîmes, France
| | - Pascale Fabbro-Peray
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology, (BESPIM), CHU Nîmes, Nîmes, France
| | | | - Florence Ménégaux
- Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
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15
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Metastasis, Mortality, and Quality of Life for Men With NCCN High and Very High Risk Localized Prostate Cancer After Surgical and/or Combined Modality Radiotherapy. Clin Genitourin Cancer 2020; 18:274-283.e5. [DOI: 10.1016/j.clgc.2019.11.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 10/31/2019] [Accepted: 11/27/2019] [Indexed: 10/24/2022]
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16
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17
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Greenberger BA, Chen VE, Den RB. Combined Modality Therapies for High-Risk Prostate Cancer: Narrative Review of Current Understanding and New Directions. Front Oncol 2019; 9:1273. [PMID: 31850194 PMCID: PMC6896415 DOI: 10.3389/fonc.2019.01273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/04/2019] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Benjamin A Greenberger
- Department of Radiation Oncology, Sidney Kimmel Medical College and Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Victor E Chen
- Department of Radiation Oncology, Sidney Kimmel Medical College and Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Robert B Den
- Department of Radiation Oncology, Sidney Kimmel Medical College and Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
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18
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Greenberger BA, Zaorsky NG, Den RB. 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. Eur Urol Focus 2019; 6:404-418. [PMID: 31813810 DOI: 10.1016/j.euf.2019.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/03/2019] [Accepted: 11/03/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Benjamin A Greenberger
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Robert B Den
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA, USA
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19
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Boehle A, Katic K, König IR, Robrahn-Nitschke I, Brandenburg B. Comparison of outcome endpoints in intermediate- and high-risk prostate cancer after combined-modality radiotherapy. Brachytherapy 2019; 19:24-32. [PMID: 31629640 DOI: 10.1016/j.brachy.2019.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 08/08/2019] [Accepted: 09/05/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE To compare a standard radio-oncological and a surgical biochemical failure definition after combined-modality radiation therapy (CRT) in men with intermediate- and high-risk prostate cancer. METHODS 425 men were treated with external beam radiotherapy (59.4 Gy, 33 fractions) and 125J seed-brachytherapy (S-BT, 100 Gy). Biochemical recurrence (BR) was defined either as radio-oncologic (rBR), using a +2 ng/mL prostate-specific antigen (PSA) increase above a nadir value, or as surgical (sBR), using a 2-year posttreatment PSA of ≥0.2 ng/mL. Biochemical recurrence-free, metastasis-free, cancer-specific, and overall survival were calculated at 5 and 10 years using the Kaplan-Meier method. Standard validation tests were used to compare both thresholds. RESULTS After a median of 7 years, overall recurrence rates were 10.4% and 31.5% for rBR and sBR definitions, respectively. Both failure definitions proved sensitive for the prediction of metastases and cancer-specific death, whereas the rBR definition was significantly more specific. The accuracies of a correct prediction of metastases and death of prostate cancer were 73.1% vs. 96.2% and 72.2% vs. 92.9% for sBR vs. rBR, respectively. The inferior validity results of the sBR definition were attributable to a PSA-bounce phenomenon occurring in 56% of patients with sBR. Still, using the less suitable sBR definition, the results of CRT compared favorably to BRFS rates of surgical interventions. CONCLUSION After CRT, the radio-oncological (aka Phoenix) failure definition is more reliable than a fixed surgical endpoint. Exclusively in high-risk patients, sBR offers a direct comparison across surgical and nonsurgical treatment options at 5 and 10 years.
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Affiliation(s)
- Andreas Boehle
- Dept. of Urology, University of Luebeck, Luebeck, Germany; HELIOS Agnes-Karll Hospital Bad Schwartau, Bad Schwartau, Germany.
| | | | - Inke R König
- Institute for Medical Biometry and Statistics, University of Luebeck, Luebeck, Germany
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Guo Y, Mao S, Zhang A, Zhang J, Wang L, Wang R, Zhang W, Zhang Z, Wu Y, Cao X, Yang B, Yao X. Survival Significance of Patients With Low Prostate-Specific Antigen and High-Grade Prostate Cancer After Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy With Brachytherapy. Front Oncol 2019; 9:638. [PMID: 31380277 PMCID: PMC6659440 DOI: 10.3389/fonc.2019.00638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/28/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: This study compared survival of prostate cancer patients with low prostate specific antigen level (PSA ≤ 10 ng/ml) and high-grades of Gleason score (GS) of 8–10 with different treatment options (i.e., radical prostatectomy [RP], external beam radiotherapy [EBRT], or external beam radiotherapy with brachytherapy [EBRT+BT]). Materials and Methods: The Surveillance, Epidemiology and End Results (SEER) database data (2004–2013), and overall survival (OS) and prostate cancer-specific mortality (PCSM), were evaluated using the Cox proportional hazards regression model and Fine and Gray competing risk model. Results: The SEER data contained 9,114 patients, 4,175 of whom received RP, 4,114 received EBRT, and 825 received EBRT+BT with a median follow-up duration of 47 months. RP patients had significantly better OS than patients with EBRT and EBRT+BT (adjusted HR [AHR]: 3.36, 95% CI: 2.43–4.64, P < 0.001; AHR: 2.15, 95% CI: 1.32–3.48, P = 0.002; respectively). There was no statistical difference in PCSM between RP and EBRT+BT (AHR: 1.31, 95% CI: 0.61–2.80, P = 0.485), while EBRT had worse OS (P < 0.05). The subgroup analysis revealed that there was no statistical difference in prognosis of patients with age of >70 years old, or PSA levels of ≤ 2.5 ng/ml between RP and EBRT+BT (P > 0.05). Conclusion: RP patients with low PSA levels and high GS had better OS compared to either EBRT or EBRT+BT, while RP and EBRT+BT resulted in significantly lower PCSM, compared to EBRT. Moreover, EBRT+BT and RP were associated with similar survival of patients with age of > 70 years old, or PSA levels of ≤ 2.5 ng/ml.
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Affiliation(s)
- Yadong Guo
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Shiyu Mao
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Aihong Zhang
- Department of Medical Statistics, Tongji University School of Medicine, Shanghai, China
| | - Junfeng Zhang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Longsheng Wang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ruiliang Wang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Wentao Zhang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ziwei Zhang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Yuan Wu
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xuan Cao
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Bin Yang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xudong Yao
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
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Decision Support Systems in Prostate Cancer Treatment: An Overview. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4961768. [PMID: 31281840 PMCID: PMC6590598 DOI: 10.1155/2019/4961768] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 04/02/2019] [Accepted: 05/06/2019] [Indexed: 12/11/2022]
Abstract
Background A multifactorial decision support system (mDSS) is a tool designed to improve the clinical decision-making process, while using clinical inputs for an individual patient to generate case-specific advice. The study provides an overview of the literature to analyze current available mDSS focused on prostate cancer (PCa), in order to better understand the availability of decision support tools as well as where the current literature is lacking. Methods We performed a MEDLINE literature search in July 2018. We divided the included studies into different sections: diagnostic, which aids in detection or staging of PCa; treatment, supporting the decision between treatment modalities; and patient, which focusses on informing the patient. We manually screened and excluded studies that did not contain an mDSS concerning prostate cancer and study proposals. Results Our search resulted in twelve diagnostic mDSS; six treatment mDSS; two patient mDSS; and eight papers that could improve mDSS. Conclusions Diagnosis mDSS is well represented in the literature as well as treatment mDSS considering external-beam radiotherapy; however, there is a lack of mDSS for other treatment modalities. The development of patient decision aids is a new field of research, and few successes have been made for PCa patients. These tools can improve personalized medicine but need to overcome a number of difficulties to be successful and require more research.
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Reichard CA, Hoffman KE, Tang C, Williams SB, Allen PK, Achim MF, Kuban DA, Chapin BF. Radical prostatectomy or radiotherapy for high- and very high-risk prostate cancer: a multidisciplinary prostate cancer clinic experience of patients eligible for either treatment. BJU Int 2019; 124:811-819. [DOI: 10.1111/bju.14780] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Chad A. Reichard
- Department of Urology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Karen E. Hoffman
- Department of Radiation Oncology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Chad Tang
- Department of Radiation Oncology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Stephen B. Williams
- Department of Surgery; Division of Urology; The University of Texas Medical Branch; Galveston TX USA
| | - Pamela K. Allen
- Department of Radiation Oncology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Mary F. Achim
- Department of Urology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Deborah A. Kuban
- Department of Radiation Oncology; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Brian F. Chapin
- Department of Urology; The University of Texas MD Anderson Cancer Center; Houston TX USA
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23
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Dess RT, Soni PD, Jackson WC, Berlin A, Cox BW, Jolly S, Efstathiou JA, Feng FY, Kishan AU, Stish BJ, Pisansky TM, Spratt DE. The current state of randomized clinical trial evidence for prostate brachytherapy. Urol Oncol 2019; 37:599-610. [PMID: 31060795 DOI: 10.1016/j.urolonc.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 02/06/2023]
Abstract
Interstitial brachytherapy is one of several curative therapeutic options for the treatment of localized prostate cancer. In this review, we summarize all available randomized data to support the optimal use of prostate brachytherapy. Evidence from completed randomized controlled trials is the focus of this review with a presentation also of important ongoing trials. Gaps in knowledge are identified where future investigation may be fruitful with intent to inspire well-designed prospective studies with standardized treatment that focuses on improving oncological outcomes, reducing morbidity, or maintaining quality of life.
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Affiliation(s)
- Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI.
| | - Payal D Soni
- Department of Radiation Oncology, Hunter Holmes McGuire VA Medical Center, Richmond, VA
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Brett W Cox
- Department of Radiation Medicine, Northwell Health, Hofstra Northwell School of Medicine, Hempstead, NY
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Felix Y Feng
- Departments of Radiation Oncology, Urology and Medicine, University of California San Francisco, San Francisco, CA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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24
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Reis LO, Montenegro R, Trinh QD. Radical prostatectomy for high-risk prostate cancer | Opinion: YES. Int Braz J Urol 2019; 45:424-427. [PMID: 31149789 PMCID: PMC6786109 DOI: 10.1590/s1677-5538.ibju.2019.03.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 11/22/2022] Open
Affiliation(s)
- Leonardo O. Reis
- UroScience, Pontifícia Universidade de Campinas - PUC, Campinas, SP, Brasil
- Departamento de Urologia, Universidade Estadual de Campinas - UNICAMP, Campinas, SP, Brasil
| | - Rodrigo Montenegro
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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25
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Kishan AU, Cook RR, King CR. Reply to Marieke J. Krimphove, Junaid Nabi, Alexander P. Cole, and Quoc-Dien Trinh's Letter to the Editor re: Ronald D. Ennis, Liangyuan Hu, Shannon N. Ryemon, Joyce Lin, Madhu Mazumdar. Brachytherapy-based Radiotherapy and Radical Prostatectomy Are Associated with Similar Survival in High-risk Localized Prostate Cancer. J Clin Oncol 2018;36:1192-8: Setting the Standard: The Importance of Defining the Standard of Care for Comparative Effectiveness Analyses. Eur Urol Oncol 2019; 2:224-225. [PMID: 31017101 DOI: 10.1016/j.euo.2018.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 08/23/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Amar U Kishan
- Radiation Oncology, University of California, Los Angeles, CA, USA.
| | - Ryan R Cook
- Radiation Oncology, University of California, Los Angeles, CA, USA
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26
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Berg S, Cole AP, Krimphove MJ, Nabi J, Marchese M, Lipsitz SR, Noldus J, Choueiri TK, Kibel AS, Trinh QD. Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer. Eur Urol 2019; 75:552-555. [DOI: 10.1016/j.eururo.2018.10.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 10/17/2018] [Indexed: 10/27/2022]
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Muñoz-Rodríguez J, Hannaoui N, Domínguez A, Centeno C, Parejo V, Rosado M, Prats J, Navarro S. Impact of the baseline study with penile doppler ultrasound in patients with prostate cancer before radical prostatectomy. Actas Urol Esp 2019; 43:84-90. [PMID: 30360903 DOI: 10.1016/j.acuro.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Given the high prevalence of erectile dysfunction in male population between 40-70 years old and the effect of radical prostatectomy on this domain, it is important to perform a baseline study. MATERIAL AND METHODS Prior radical prostatectomy, erectile function has been assessed prospectively in 112 prostate cancer patients using the erectile function (EF) domain of the International Index of Erectile Function (EF-IIEF), Erectile Hardness Score (EHS) and a penile doppler ultrasound (PDUS). Comorbidities and Charlson index were collected. The EORTC QLQ C-30 and PR-25 tests were administered. RESULTS According to EF-IIEF questionnaire, 50.9% of patients showed normal EF and EHS grade 3-4 erection was achieved in the 75.9%. PDUS was normal only in 28.6% of patients and 51.8% showed arterial insufficiency. We found a significant association (P<.0001) between categorized EF-IIEF (normal, mild/moderate/severe) and the EHS value. Between PDUS (normal vs. pathologic) and EHS (3-4 vs. 1-2) statistically significant association (P=.005) was found. Just 35.3% of patients with EHS 3-4 showed normal PDUS. Correlation between the PDUS and the EF-IIEF (≥26 vs.<26) was statistically significant (P=.043). Moreover, only 38.6% of patients with EF-IIEF≥26 had a normal PDUS. CONCLUSIONS In order to predict EF recovery after surgery, global assessment is required. Solely self-administered tests are not enough. In this baseline study, PDUS can play an important role.
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Mahal BA, Butler S, Franco I, Spratt DE, Rebbeck TR, D’Amico AV, Nguyen PL. Use of Active Surveillance or Watchful Waiting for Low-Risk Prostate Cancer and Management Trends Across Risk Groups in the United States, 2010-2015. JAMA 2019; 321:704-706. [PMID: 30743264 PMCID: PMC6439610 DOI: 10.1001/jama.2018.19941] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cancer epidemiology study uses SEER data to examine US trends in use of active surveillance, watchful waiting, radiotherapy, and surgical management of localized prostate cancer among men with low-, intermediate-, and high-risk disease treated between 2010 and 2015.
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Affiliation(s)
- Brandon A. Mahal
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Santino Butler
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Idalid Franco
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Timothy R. Rebbeck
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Anthony V. D’Amico
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Paul L. Nguyen
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts
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29
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Beesley LJ, Morgan TM, Spratt DE, Singhal U, Feng FY, Furgal AC, Jackson WC, Daignault S, Taylor JMG. Individual and Population Comparisons of Surgery and Radiotherapy Outcomes in Prostate Cancer Using Bayesian Multistate Models. JAMA Netw Open 2019; 2:e187765. [PMID: 30707231 PMCID: PMC6484613 DOI: 10.1001/jamanetworkopen.2018.7765] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Whether surgery or radiotherapy is the preferred treatment for patients with localized prostate cancer continues to be debated, and randomized clinical trials cannot yet fully address this question. Furthermore, there may be heterogeneity in responses, and the optimal treatment for a patient will depend on his clinical and tumor characteristics. OBJECTIVES To use a unified statistical approach to compare the association of surgery and radiotherapy with both metastatic clinical failure (CF) and survival in localized prostate cancer and to develop an online calculator for individualized, treatment-specific outcome prediction. DESIGN, SETTING, AND PARTICIPANTS Cohort study for statistical analysis and development of individualized predictions using Bayesian multistate models that jointly consider both CF and survival and adjust for confounding factors. This study used data from patients treated at the University of Michigan between January 1, 1996, and July 1, 2013, with detailed information on treatment, patient and tumor characteristics, and outcomes. Primary analyses were performed in 2017 and 2018. Participants were a cohort of 4544 patients with localized prostate cancer undergoing primary treatment. EXPOSURES Radical prostatectomy and external beam radiotherapy. MAIN OUTCOMES AND MEASURES The clinical outcomes were metastatic CF, death after CF, and death from other causes. The adjustment factors were age, prostate gland volume, prostate-specific antigen level, comorbidities, Gleason score, perineural invasion, cT category, race, and treatment year. An online calculator was developed to estimate risks for multiple outcomes for any patient based on 2 treatment choices and on his clinical and tumor characteristics. RESULTS Among 4544 men (mean [SD] age, 61.2 [8.0] years), 3769 underwent radical prostatectomy, 775 received external beam radiotherapy, 157 (3.5%) had CF, 90 (2.0%) died after CF, and 378 (8.3%) died of other causes. Across all patients, there was no significant difference in risk of CF for surgery vs radiotherapy (hazard ratio, 0.80; 95% CI, 0.52-1.23). However, using multistate models, in some cases individualized predictions resulted in different expected outcomes between surgery and radiotherapy for a given patient. CONCLUSIONS AND RELEVANCE In this study, after adjustment for measured confounders, the hazard of CF was similar between treatments on average. However, these data indicate a greater oncologic benefit for some individual patients if treated with surgery and for other patients if treated with radiotherapy. Individualized predictions provide a novel approach to facilitate treatment decision making.
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Affiliation(s)
| | - Todd M. Morgan
- Department of Urology, University of Michigan, Ann Arbor
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Udit Singhal
- Department of Urology, University of Michigan, Ann Arbor
| | - Felix Y. Feng
- Department of Radiation Oncology, University of California, San Francisco
| | | | | | | | - Jeremy M. G. Taylor
- Department of Biostatistics, University of Michigan, Ann Arbor
- Department of Radiation Oncology, University of Michigan, Ann Arbor
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30
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Spratt DE, Carroll PR. Optimal Radical Therapy for Localized Prostate Cancer: Recreation of the Self-Fulfilling Prophecy With Combination Brachytherapy? J Clin Oncol 2018; 36:2914-2917. [DOI: 10.1200/jco.2018.78.6236] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Daniel E. Spratt
- Daniel E. Spratt, University of Michigan, Ann Arbor, MI; and Peter R. Carroll, University of California San Francisco, San Francisco, CA
| | - Peter R. Carroll
- Daniel E. Spratt, University of Michigan, Ann Arbor, MI; and Peter R. Carroll, University of California San Francisco, San Francisco, CA
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31
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Takamoto A, Tanimoto R, Bekku K, Araki M, Sadahira T, Wada K, Ebara S, Katayama N, Yanai H, Nasu Y. Oncological impact of neoadjuvant hormonal therapy on permanent iodine-125 seed brachytherapy in patients with low- and intermediate-risk prostate cancer. Int J Urol 2018; 25:507-512. [PMID: 29651796 DOI: 10.1111/iju.13555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 02/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether neoadjuvant hormonal therapy improves oncological outcomes of patients with localized prostate cancer treated with permanent brachytherapy. METHODS Between January 2004 and November 2014, 564 patients underwent transperineal ultrasonography-guided permanent iodine-125 seed brachytherapy. We retrospectively analyzed low- or intermediate-risk prostate cancer based on the National Comprehensive Cancer Network guidelines. The clinical variables were evaluated for influence on biochemical recurrence-free survival, progression-free survival, cancer-specific survival and overall survival. RESULTS A total of 484 patients with low-risk (259 patients) or intermediate-risk disease (225 patients) were evaluated. Of these, 188 received neoadjuvant hormonal therapy. With a median follow up of 71 months, the 5-year actuarial biochemical recurrence-free survival rates of patients who did and did not receive neoadjuvant hormonal therapy were 92.9% and 93.6%, respectively (P = 0.2843). When patients were stratified by risk group, neoadjuvant hormonal therapy did not improve biochemical recurrence-free survival outcomes in low- (P = 0.8949) or intermediate-risk (P = 0.1989) patients. The duration or type of hormonal therapy was not significant in predicting biochemical recurrence. In a multivariate analysis, Gleason score, pretreatment prostate-specific antigen, clinical T stage, and prostate dosimetry, primary Gleason score and positive core rate were significant predictive factors of biochemical recurrence-free survival, whereas neoadjuvant hormonal therapy was insignificant. Furthermore, neoadjuvant hormonal therapy did not significantly influence progression-free survival, cancer-specific survival or overall survival. CONCLUSIONS In patients with low- or intermediate-risk disease treated with permanent prostate brachytherapy, neoadjuvant hormonal therapy does not improve oncological outcomes. Its use should be restricted to patients who require prostate volume reduction.
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Affiliation(s)
- Atsushi Takamoto
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ryuta Tanimoto
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kensuke Bekku
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takuya Sadahira
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koichiro Wada
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shin Ebara
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Norihisa Katayama
- Department of Radiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Yanai
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasutomo Nasu
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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32
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Roach M. Re: Morbidity and Mortality of Locally Advanced Prostate Cancer: A Population Based Analysis Comparing Radical Prostatectomy Versus External Beam Radiation. Eur Urol 2018; 73:638-639. [DOI: 10.1016/j.eururo.2017.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/07/2017] [Indexed: 10/18/2022]
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Kishan AU, Cook RR, Ciezki JP, Ross AE, Pomerantz MM, Nguyen PL, Shaikh T, Tran PT, Sandler KA, Stock RG, Merrick GS, Demanes DJ, Spratt DE, Abu-Isa EI, Wedde TB, Lilleby W, Krauss DJ, Shaw GK, Alam R, Reddy CA, Stephenson AJ, Klein EA, Song DY, Tosoian JJ, Hegde JV, Yoo SM, Fiano R, D’Amico AV, Nickols NG, Aronson WJ, Sadeghi A, Greco S, Deville C, McNutt T, DeWeese TL, Reiter RE, Said JW, Steinberg ML, Horwitz EM, Kupelian PA, King CR. Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy With Brachytherapy Boost and Disease Progression and Mortality in Patients With Gleason Score 9-10 Prostate Cancer. JAMA 2018; 319:896-905. [PMID: 29509865 PMCID: PMC5885899 DOI: 10.1001/jama.2018.0587] [Citation(s) in RCA: 224] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE The optimal treatment for Gleason score 9-10 prostate cancer is unknown. OBJECTIVE To compare clinical outcomes of patients with Gleason score 9-10 prostate cancer after definitive treatment. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study in 12 tertiary centers (11 in the United States, 1 in Norway), with 1809 patients treated between 2000 and 2013. EXPOSURES Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy, or EBRT plus brachytherapy boost (EBRT+BT) with androgen deprivation therapy. MAIN OUTCOMES AND MEASURES The primary outcome was prostate cancer-specific mortality; distant metastasis-free survival and overall survival were secondary outcomes. RESULTS Of 1809 men, 639 underwent RP, 734 EBRT, and 436 EBRT+BT. Median ages were 61, 67.7, and 67.5 years; median follow-up was 4.2, 5.1, and 6.3 years, respectively. By 10 years, 91 RP, 186 EBRT, and 90 EBRT+BT patients had died. Adjusted 5-year prostate cancer-specific mortality rates were RP, 12% (95% CI, 8%-17%); EBRT, 13% (95% CI, 8%-19%); and EBRT+BT, 3% (95% CI, 1%-5%). EBRT+BT was associated with significantly lower prostate cancer-specific mortality than either RP or EBRT (cause-specific HRs of 0.38 [95% CI, 0.21-0.68] and 0.41 [95% CI, 0.24-0.71]). Adjusted 5-year incidence rates of distant metastasis were RP, 24% (95% CI, 19%-30%); EBRT, 24% (95% CI, 20%-28%); and EBRT+BT, 8% (95% CI, 5%-11%). EBRT+BT was associated with a significantly lower rate of distant metastasis (propensity-score-adjusted cause-specific HRs of 0.27 [95% CI, 0.17-0.43] for RP and 0.30 [95% CI, 0.19-0.47] for EBRT). Adjusted 7.5-year all-cause mortality rates were RP, 17% (95% CI, 11%-23%); EBRT, 18% (95% CI, 14%-24%); and EBRT+BT, 10% (95% CI, 7%-13%). Within the first 7.5 years of follow-up, EBRT+BT was associated with significantly lower all-cause mortality (cause-specific HRs of 0.66 [95% CI, 0.46-0.96] for RP and 0.61 [95% CI, 0.45-0.84] for EBRT). After the first 7.5 years, the corresponding HRs were 1.16 (95% CI, 0.70-1.92) and 0.87 (95% CI, 0.57-1.32). No significant differences in prostate cancer-specific mortality, distant metastasis, or all-cause mortality (≤7.5 and >7.5 years) were found between men treated with EBRT or RP (cause-specific HRs of 0.92 [95% CI, 0.67-1.26], 0.90 [95% CI, 0.70-1.14], 1.07 [95% CI, 0.80-1.44], and 1.34 [95% CI, 0.85-2.11]). CONCLUSIONS AND RELEVANCE Among patients with Gleason score 9-10 prostate cancer, treatment with EBRT+BT with androgen deprivation therapy was associated with significantly better prostate cancer-specific mortality and longer time to distant metastasis compared with EBRT with androgen deprivation therapy or with RP.
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Affiliation(s)
- Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles
| | - Ryan R. Cook
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Jay P. Ciezki
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Ashley E. Ross
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark M. Pomerantz
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Paul L. Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Phuoc T. Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kiri A. Sandler
- Department of Radiation Oncology, University of California, Los Angeles
| | - Richard G. Stock
- Department of Radiation Oncology, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregory S. Merrick
- Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
| | | | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Eyad I. Abu-Isa
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Trude B. Wedde
- Department of Oncology, Oslo University Hospital, the Norwegian Radium Hospital, Oslo, Norway
| | - Wolfgang Lilleby
- Department of Oncology, Oslo University Hospital, the Norwegian Radium Hospital, Oslo, Norway
| | - Daniel J. Krauss
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Grace K. Shaw
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Ridwan Alam
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Andrew J. Stephenson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric A. Klein
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel Y. Song
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey J. Tosoian
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John V. Hegde
- Department of Radiation Oncology, University of California, Los Angeles
| | - Sun Mi Yoo
- Department of Radiation Oncology, University of California, Los Angeles
| | - Ryan Fiano
- Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
| | - Anthony V. D’Amico
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California, Los Angeles
- Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Ahmad Sadeghi
- Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Stephen Greco
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Theodore L. DeWeese
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Eric M. Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Patrick A. Kupelian
- Department of Radiation Oncology, University of California, Los Angeles
- Varian Medical Systems, Palo Alto, California
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Markovina S, Meeks MW, Badiyan S, Vetter J, Gay HA, Paradis A, Michalski J, Sandhu G. Superior metastasis-free survival for patients with high-risk prostate cancer treated with definitive radiation therapy compared to radical prostatectomy: A propensity score-matched analysis. Adv Radiat Oncol 2017; 3:190-196. [PMID: 29904744 PMCID: PMC6000029 DOI: 10.1016/j.adro.2017.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/18/2017] [Accepted: 12/06/2017] [Indexed: 11/26/2022] Open
Abstract
Purpose For high-risk prostate cancer (HR-PCa) in men with a life expectancy of at least 10 years, the National Comprehensive Cancer Network recommends radiation therapy (RT) plus androgen deprivation therapy (ADT) with category 1 evidence or radical prostatectomy (RP) as an acceptable initial therapy. Randomized evidence regarding which therapy is optimal for disease control is lacking for men with HR-PCa. We performed a propensity-score-matched comparison of outcomes for men with localized HR-PCa treated with primary RT or RP. Methods and materials The medical records of patients with localized HR-PCa who were treated at our institution between 2002 and 2011 were reviewed. Patient and disease characteristics, treatment details, and outcomes were collected. A combination of nearest-neighbor propensity score matching on age, Adult Comorbidity Evaluation-27 comorbidity index, prostate-specific antigen, biopsy Gleason scores, and clinical T-stage as well as exact matching on prostate-specific antigen, biopsy Gleason scores, and clinical T-stage was performed. Outcomes were measured from diagnosis. Multivariate Cox proportional hazards regression was used to compare metastasis-free and overall survival. Results A total of 246 patients were identified with 62 propensity-score-matched pairs. ADT was administered to 6.5% and 80.6% of patients receiving RP and RT, respectively. Five-year rates of metastasis for RP and RT were 33% and 8.9%, respectively (P = .003). Overall survival was not different. Delay of salvage therapy was longer for patients undergoing primary RT (P < .001). Findings were similar when only those patients who did not receive ADT were compared. Conclusions At our institution, treatment with primary RT resulted in superior metastasis-free survival over RP. This was not accompanied by an improvement in OS.
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Affiliation(s)
- Stephanie Markovina
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Marshall W Meeks
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Shahed Badiyan
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joel Vetter
- Division of Urologic Surgery, Washington University, St. Louis, Missouri
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Alethea Paradis
- Division of Urologic Surgery, Washington University, St. Louis, Missouri
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Gurdarshan Sandhu
- Division of Urologic Surgery, Washington University, St. Louis, Missouri
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Chen C, Chen Z, Wang K, Hu L, Xu R, He X. Comparisons of health-related quality of life among surgery and radiotherapy for localized prostate cancer: a systematic review and meta-analysis. Oncotarget 2017; 8:99057-99065. [PMID: 29228751 PMCID: PMC5716791 DOI: 10.18632/oncotarget.21519] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 09/22/2017] [Indexed: 01/20/2023] Open
Abstract
The objective of this study is to compare health-related quality of life (QOL) outcomes between radical prostatectomy (RP) and external beam radiation therapy (EBRT) for localized prostate cancer. PubMed, EMBASE, the Cochrane Library and Web of Science (to July 2017) were searched. Pooled analysis of each domain-specific score was calculated in relevant studies, and its change with follow-up time was explored by sub-group analysis. A total of six studies containing 4423 patients were included. Men underwent RP was associated with worse urinary and sexual domain score than EBRT (standardized mean difference (SMD) = -0.59, -0.58; 95% confidence interval (CI) = -0.73 to -0.45, -0.72 to -0.44). In contrast, EBRT group had lower bowel domain score than RP group (SMD = 0.42, 95% CI = 0.33 to 0.52). The sub-group analysis revealed the most severe urinary and sexual QOL in RP as well as bowel QOL in EBRT group all happened in the first month post operation. The different performance of two treatments in three QOL domains diminished afterwards. Health-related QOL should be considered comprehensively when planning follow-up for men after RP or EBRT for localized prostate cancer.
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Affiliation(s)
- Cheng Chen
- Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, P.R. China
| | - Zhen Chen
- Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, P.R. China
| | - Kun Wang
- Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, P.R. China
| | - Linkun Hu
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, P.R. China
| | - Renfang Xu
- Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, P.R. China
| | - Xiaozhou He
- Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, P.R. China
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Wallis CJD, Glaser A, Hu JC, Huland H, Lawrentschuk N, Moon D, Murphy DG, Nguyen PL, Resnick MJ, Nam RK. Survival and Complications Following Surgery and Radiation for Localized Prostate Cancer: An International Collaborative Review. Eur Urol 2017; 73:11-20. [PMID: 28610779 DOI: 10.1016/j.eururo.2017.05.055] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/30/2017] [Indexed: 10/24/2022]
Abstract
BACKGROUND Evaluation of treatment options for localized prostate cancer (PCa) remains among the highest priorities for comparative effectiveness research. Surgery and radiotherapy (RT) are the two interventions most commonly used. OBJECTIVE To provide a critical narrative review of evidence of the comparative effectiveness and harms of surgery and RT in the treatment of localized PCa. EVIDENCE ACQUISITION A collaborative critical narrative review of the literature was conducted. EVIDENCE SYNTHESIS Evidence to clearly guide treatment choice in PCa remains insufficient. Randomized trials are underpowered for clinically meaningful endpoints and have demonstrated no difference in overall or PCa-specific survival. Observational studies have consistently demonstrated an absolute survival benefit for men treated with radical prostatectomy, but are limited by selection bias and residual confounding errors. Surgery and RT are associated with comparable health-related quality of life following treatment in three randomized trials. Randomized data regarding urinary, erectile, and bowel function show few long-term (>5 yr) differences, although short-term continence and erectile function were worse following surgery and short-term urinary bother and bowel function were worse following RT. There has been recent recognition of other complications that may significantly affect the life trajectory of those undergoing PCa treatment. Of these, hospitalization, the need for urologic, rectoanal, and other major surgical procedures, and secondary cancers are more common among men treated with RT. Androgen deprivation therapy, frequently co-administered with RT, may additionally contribute to treatment-related morbidity. Technological innovations in surgery and RT have shown inconsistent oncologic and functional benefits. CONCLUSIONS Owing to underpowered randomized control studies and the selection biases inherent in observational studies, the question of which treatment provides better PCa control cannot be definitively answered now or in the near future. Complications following PCa treatment are relatively common regardless of treatment approach. These include the commonly identified issues of urinary incontinence and erectile dysfunction, and others including hospitalization and invasive procedures to manage complications and secondary malignancies. Population-based outcome studies, rather than clinical trial data, will be necessary for a comprehensive understanding of the relative benefits and risks of each therapeutic approach. PATIENT SUMMARY Surgery and radiotherapy are the most common interventions for men diagnosed with prostate cancer. Comparisons of survival after these treatments are limited by various flaws in the relevant studies. Complications are common regardless of the treatment approach.
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Affiliation(s)
- Christopher J D Wallis
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Adam Glaser
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Hartwig Huland
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Nathan Lawrentschuk
- Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia; Olivia Newton-John Cancer Research Institute, Austin Health, Melbourne, Australia; Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Daniel Moon
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Central Clinical School, Monash University, Clayton, Australia; The Epworth Prostate Centre, Epworth Hospital, Richmond, Australia
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; The Epworth Prostate Centre, Epworth Hospital, Richmond, Australia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley VA Health Care System, Nashville, TN, USA
| | - Robert K Nam
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada.
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Durante M, Orecchia R, Loeffler JS. Charged-particle therapy in cancer: clinical uses and future perspectives. Nat Rev Clin Oncol 2017; 14:483-495. [DOI: 10.1038/nrclinonc.2017.30] [Citation(s) in RCA: 241] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Prostate Cancer Radiation Therapy: What Do Clinicians Have to Know? BIOMED RESEARCH INTERNATIONAL 2016; 2016:6829875. [PMID: 28116302 PMCID: PMC5225325 DOI: 10.1155/2016/6829875] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/18/2016] [Accepted: 10/31/2016] [Indexed: 12/11/2022]
Abstract
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.
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Higher sexual interest with androgen receptor inhibitor monotherapy than with castration plus an androgen receptor inhibitor in prostate cancer patients treated with curative radiotherapy, but otherwise small health-related quality of life differences: A randomised prospective 18-month follow-up study. Eur J Cancer 2016; 65:43-51. [PMID: 27459586 DOI: 10.1016/j.ejca.2016.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 06/11/2016] [Accepted: 06/14/2016] [Indexed: 11/22/2022]
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Roach M. Should Treatment with Radiation and Androgen Deprivation Therapy be Considered the ‘Gold Standard’ for Men with Unfavourable Intermediate- to High-risk and Locally Advanced Prostate Cancer? Clin Oncol (R Coll Radiol) 2016; 28:475-8. [DOI: 10.1016/j.clon.2016.04.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 03/29/2016] [Indexed: 10/21/2022]
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Roach M. Prostate cancer: Combining endocrine treatment and radiotherapy: a bright future. Nat Rev Urol 2016; 13:373-4. [PMID: 27245503 DOI: 10.1038/nrurol.2016.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Mack Roach
- Department of Radiation Oncology, University of California San Francisco, Box 1708, San Francisco, California 94143-1708, USA
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Morlacco A, Karnes RJ. High-risk prostate cancer: the role of surgical management. Crit Rev Oncol Hematol 2016; 102:135-43. [DOI: 10.1016/j.critrevonc.2016.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/08/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022] Open
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Surgery Provides Better Oncologic Outcomes than Radiation for the Treatment of Prostate Cancer. J Urol 2016; 196:308-9. [PMID: 27164515 DOI: 10.1016/j.juro.2016.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 11/23/2022]
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Lazar AA, Lizarraga TLC, Roach M. Re: Christopher J.D. Wallis, Refik Saskin, Richard Choo, et al. Surgery Versus Radiotherapy for Clinically-localized Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol 2016;70:21-30: Radical Prostatectomy Versus Radiation for Clinically Localized Prostate Cancer: Two Systematic Reviews and a Randomized Controlled Trial. Eur Urol 2016; 70:e13-e14. [PMID: 26935558 DOI: 10.1016/j.eururo.2016.02.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/12/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Ann A Lazar
- Department of Radiation Oncology, Divisions of Oral Epidemiology & Dental Public Health and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Tania L Ceron Lizarraga
- Department of Radiation Oncology, University of California San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Mack Roach
- Department of Radiation Oncology, University of California San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
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Bier S, Hennenlotter J, Rausch S, Aufderklamm S, Martzog JC, Stenzl A, Schwentner C, Todenhöfer T. Return to Work and Normal Daily Life Activity after Open and Robot-Assisted Radical Prostatectomy - A Single Surgeon Analysis. Urol Int 2016; 96:280-6. [DOI: 10.1159/000437335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 06/29/2015] [Indexed: 11/19/2022]
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Markovina S, Michalski J. Counterpoint: Unfair comparisons lead to unwarranted conclusions-Can treatment modalities for localized prostate cancer truly be compared without bias? Brachytherapy 2015. [PMID: 26219833 DOI: 10.1016/j.brachy.2015.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Stephanie Markovina
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.
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Høyer M, Muren LP, Glimelius B. The evolution of radiotherapy techniques in the management of prostate cancer. Acta Oncol 2015; 54:821-4. [PMID: 25973556 DOI: 10.3109/0284186x.2015.1048555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Morten Høyer
- Dept of Oncology, Aarhus University/Aarhus University Hospital , Aarhus , Denmark
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