Oncologic Outcomes of Radical Prostatectomy and High-Dose Intensity-Modulated Radiotherapy with Androgen-Deprivation Therapy for Relatively Young Patients with Unfavorable Intermediate-Risk Prostate Adenocarcinoma

Six-year outcomes of robot-assisted radical prostatectomy versus volumetric modulated arc therapy for localized prostate cancer: A propensity score-matched analysis

BACKGROUND

Although robot-assisted radical prostatectomy (RARP) and intensity-modulated radiotherapy are the leading respective techniques of prostatectomy and radiotherapy for localized prostate cancer, almost no study has directly compared their outcomes; none have compared mortality outcomes.

METHODS

We compared 6‑year outcomes of RARP (n = 500) and volumetric modulated arc therapy (VMAT, a rotational intensity-modulated radiotherapy, n = 360) in patients with cT1-4N0M0 prostate cancer. We assessed oncological outcomes, namely overall survival (OS), cancer-specific survival (CSS), radiological recurrence-free survival (rRFS), and biochemical recurrence-free survival (bRFS), using propensity score matching (PSM). We also assessed treatment-related complication outcomes of prostatectomy and radiotherapy.

RESULTS

The median follow-up duration was 79 months (> 6 years). PSM generated a matched cohort of 260 patients (130 per treatment group). In the matched cohort, RARP and VMAT showed equivalent results for OS, CSS, and rRFS: both achieved excellent 6‑year outcomes for OS (> 96%), CSS (> 98%), and rRFS (> 91%). VMAT had significantly longer bRFS than RARP, albeit based on different definitions of biochemical recurrence. Regarding complication outcomes, patients who underwent RARP had minimal (2.6%) severe perioperative complications and achieved excellent continence recovery (91.6 and 68.8% of the patients achieved ≤ 1 pad/day and pad-free, respectively). Patients who underwent VMAT had an acceptable rate (20.0%) of grade ≥ 2 genitourinary complications and a very low rate (4.4%) of grade ≥ 2 gastrointestinal complications.

CONCLUSION

On the basis of PSM after a 6-year follow-up, RARP and VMAT showed equivalent and excellent oncological outcomes, as well as acceptable complication profiles.

Correlation between dose-volume parameters and rectal bleeding after 12 fractions of carbon ion radiotherapy for prostate cancer

BACKGROUND

Carbon ion radiotherapy (CIRT) is currently used to treat prostate cancer. Rectal bleeding is a major cause of toxicity even with CIRT. However, to date, a correlation between the dose and volume parameters of the 12 fractions of CIRT for prostate cancer and rectal bleeding has not been shown. Similarly, the clinical risk factors for rectal bleeding were absent after 12 fractions of CIRT.

AIM

To identify the risk factors for rectal bleeding in 12 fractions of CIRT for prostate cancer.

METHODS

Among 259 patients who received 51.6 Gy [relative biological effectiveness (RBE)], in 12 fractions of CIRT, 15 had grade 1 (5.8%) and nine had grade 2 rectal bleeding (3.5%). The dose-volume parameters included the volume (cc) of the rectum irradiated with at least x Gy (RBE) (Vx) and the minimum dose in the most irradiated x cc normal rectal volume (Dx).

RESULTS

The mean values of D6cc, D2cc, V10 Gy (RBE), V20 Gy (RBE), V30 Gy (RBE), and V40 Gy (RBE) were significantly higher in the patients with rectal bleeding than in those without. The cutoff values were D6cc = 34.34 Gy (RBE), D2cc = 46.46 Gy (RBE), V10 Gy (RBE) = 9.85 cc, V20 Gy (RBE) = 7.00 cc, V30 Gy (RBE) = 6.91 cc, and V40 Gy (RBE) = 4.26 cc. The D2cc, V10 Gy (RBE), and V20 Gy (RBE) cutoff values were significant predictors of grade 2 rectal bleeding.

CONCLUSION

The above dose-volume parameters may serve as guidelines for preventing rectal bleeding after 12 fractions of CIRT for prostate cancer.

Effect of Pre-Existing Sarcopenia on Oncological Outcomes for Oral Cavity Squamous Cell Carcinoma Undergoing Curative Surgery: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study

Purpose: The effect of pre-existing sarcopenia on patients with oral cavity squamous cell carcinoma (OCSCC) remains unknown. Therefore, we designed a propensity score-matched population-based cohort study to compare the oncological outcomes of patients with OCSCC undergoing curative surgery with and without sarcopenia. Patients and Methods: We included patients with OCSCC undergoing curative surgery and categorized them into two groups according to the presence or absence of pre-existing sarcopenia. Patients in both the groups were matched at a ratio of 2:1. Results: The matching process yielded 16,294 patients (10,855 and 5439 without and with pre-existing sarcopenia, respectively). In multivariate Cox regression analyses, the adjusted hazard ratio (aHR, 95% confidence interval [CI]) of all-cause mortality for OCSCC with and without pre-existing sarcopenia was 1.15 (1.11−1.21, p < 0.0001). Furthermore, the aHRs (95% CIs) of locoregional recurrence and distant metastasis for OCSCC with and without pre-existing sarcopenia were 1.07 (1.03−1.18, p = 0.0020) and 1.07 (1.03−1.20, p = 0.0148), respectively. Conclusions: Pre-existing sarcopenia might be a significant poor prognostic factor for overall survival, locoregional recurrence, and distant metastasis for patients with OCSCC undergoing curative surgery. In susceptible patients at a risk of OCSCC, sarcopenia prevention measures should be encouraged, such as exercise and early nutrition intervention.

The Latest Data Specifically Focused on Long-Term Oncologic Prognostication for Very Old Adults with Acute Vulnerable Localized Prostate Cancer: A Nationwide Cohort Study

Purpose: Few studies have evaluated the prime treatment choice for men older than 80 years with acute vulnerable localized prostate cancer (AV-LPC). Clinicians have been deeply troubled by this near end-of-life medical choice for a very specific group of patients. We compared the oncological prognostication of very old patients with AV-LPC after they underwent either radical prostatectomy (RP) or massive-dose intensity-modulated radiotherapy (IMRT) coupled with long-term androgen deprivation therapy (ADT) over a long-term investigation. Methods: In this nationwide cohort study, we used the Taiwan Cancer Registry Database and retrieved information related to patients (aged ≥ 80 years) with AV-LPC who underwent standard RP (the RP group) or massive-dose IMRT + long-term ADT (at least 72 Gy and ADT use ≥18 months; the IMRT + ADT group). After potential confounders were controlled for using propensity score matching (PSM), we utilized the Cox proportional hazards regression to evaluate the oncologic prognostication. Results: The IMRT + ADT group had a significantly higher adjusted hazard ratio (aHR) for all-cause mortality (aHR, 2.00; 95% confidence interval [CI], 1.41−2.87) than the RP group. Analysis of the secondary outcomes revealed that compared with the RP group, the aHRs of biochemical failure, locoregional recurrence, and distant metastasis in the IMRT + ADT group were 1.77 (95% CI: 1.36−2.11, p < 0.0001), 1.12 (95% CI: 1.04−1.33, p < 0.0001), and 1.15 (95% CI: 1.06−1.71, p = 0.0311), respectively. Conclusion: RP provides more favorable oncological prognostication than IMRT in very old adults with AV-LPC.

Long-Term Medical Resource Consumption of Radical Prostatectomy vs. Intensity-Modulated Radiotherapy for Old Patients With Prostate Cancer: A Nationwide Population-Based Cohort Study

Purpose

Few studies have compared the long-term medical resource consumption between radical prostatectomy (RP) and intensity-modulated radiation therapy (IMRT) among old (≥80 years) patients with localized prostate cancer (LPC), particularly in those at high risk of prostate adenocarcinoma.

Patients and Methods

The propensity score matching was conducted to investigate the medical expenditure of two therapeutic modalities (RP and IMRT) in elderly patients with high-risk LPC (HR-LPC). The generalized linear mixed and logistic regression models were employed to evaluate the number of postdischarge visits and medical reimbursement for urinary diseases or complications and the number of hospitalizations for treatment-related complications over 5 years after treatment, respectively.

Results

Significant differences were observed in the median or mean urology clinic visit numbers across the two therapeutic modalities from the first until fifth year post treatment (p < 0.0001). After adjustment for covariates, the mean difference [95% confidence interval (CI)] of urology clinic visit numbers between RP and IMRT was 13.07 (10.45-15.49, P < 0.0001), 7.47 (8.01-14.92, P < 0.0001), 8.24 (4.59-9.90, P < 0.0001), 6.63 (3.55-11.70, P < 0.0001), and 5.02 (1.12-8.73, P < 0.0001) for the first, second, third, fourth, and fifth years, respectively. In the logistic regression multivariate model with adjustment for covariates [therapy type, age, diagnosis year, income, hospital area, hospital level (academic or nonacademic), clinical and pathological T-stage, grade (Gleason score), pretreatment PSA level (ng/ml), and D'Amico risk classification], the adjusted odds ratio (95% CI) of IMRT was 2.10 (1.37-2.56, P = 0.0013), 1.55 (1.08-2.21, P = 0.0151), 1.35 (1.08-2.21, P = 0.0084), 1.24 (1.07-2.21, P = 0.0071), and 1.09 (1.02-1.81, P = 0.0379) for the first, second, third, fourth, and fifth years, respectively, compared with those of RP. The mean difference (95% CI) of total medical claims amounts of RP and IMRT between the RP and IMRT + ADT groups was 2,69,823 New Taiwan Dollars (NTD) (247,676-291,970, P < 0.0001), 40,803 NTD (17,379-54,228, P < 0.0001), 36,202 NTD (24,375-68,029, P < 0.0001), 26,708 NTD (11,179-54,595, P = 0.0321), and 12,173 NTD (17,140-41,487, P = 0.0187) for the first, second, third, fourth, and fifth years, respectively.

Conclusion

The long-term medical resource consumption was higher in old men with HR-LPC undergoing IMRT than in those undergoing RP.

Acute, Subchronic, and Chronic Complications of Radical Prostatectomy Versus Radiotherapy With Hormone Therapy in Older Adults With High-Risk Prostate Adenocarcinoma

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.

Comparison of Clinical Outcomes of Radical Prostatectomy versus IMRT with Long-Term Hormone Therapy for Relatively Young Patients with High- to Very High-Risk Localized Prostate Cancer

Simple Summary

That the definitive optimal treatments for relatively young men (aged ≤ 65 years) with high- or very high-risk localized prostate cancer (HR/VHR-LPC) are radical prostatectomy (RP) or radiation plus antiandrogen therapy (RT-ADT) is controversial. To the best of our knowledge, our study is the first and largest to examine biochemical failure (BF), all-cause death, locoregional recurrence, and distant metastasis in relatively young men with HR/VHR-LPC as defined by National Comprehensive Cancer Network risk strata. After head-to-head propensity score matching was used to balance the potential confounders, a multivariable Cox proportional hazards regression model was used to analyze oncologic outcomes. In relatively young men with HR/VHR-LPC, RP and RT-ADT yielded similar oncologic outcomes and RP reduced the risk of BF compared with RT-ADT.

Abstract

That intensity-modulated radiotherapy (IMRT) plus antiandrogen therapy (IMRT-ADT) and radical prostatectomy (RP) are the definitive optimal treatments for relatively young patients (aged ≤ 65 years) with high- or very high-risk localized prostate cancer (HR/VHR-LPC), but remains controversial. We conducted a national population-based cohort study by using propensity score matching (PSM) to evaluate the clinical outcomes of RP and IMRT-ADT in relatively young patients with HR/VHR-LPC. Methods: We used the Taiwan Cancer Registry database to evaluate clinical outcomes in relatively young (aged ≤ 65 years) patients with HR/VHR-LPC, as defined by the National Comprehensive Cancer Network risk strata. The patients had received RP or IMRT-ADT (high-dose, ≥72 Gy plus long-term, 1.5–3 years, ADT). Head-to-head PSM was used to balance potential confounders. A Cox proportional hazards regression model was used to analyze oncologic outcomes. Results: High-dose IMRT-ADT had a higher risk of biochemical failure (adjusted hazard ratio [aHR] = 2.03, 95% confidence interval [CI] 1.56–2.65, p < 0.0001) compared with RP; IMRT-ADT did not have an increased risk of all-cause death (aHR = 1.2, 95% CI 0.65–2.24, p = 0.564), locoregional recurrence (aHR = 0.88, 95% CI 0.67–1.06, p = 0.3524), or distant metastasis (aHR = 1.03, 95% CI 0.56–1.9, p = 0.9176) compared with RP. Conclusion: In relatively young patients with HR/VHR-LPC, RP and IMRT-ADT yielded similar oncologic outcomes and RP reduced the risk of biochemical failure compared with IMRT-ADT.