To the Editor Among 1809 men with prostate cancer and a Gleason score of 9 to 10, Dr Kishan and colleagues1 reported lower prostate cancer–specific mortality and longer time to distant metastases in men treated with external beam radiotherapy (EBRT) plus brachytherapy (BT) compared with radical prostatectomy or EBRT alone.
Although the authors acknowledged the limitations of the retrospective study, other confounders and biases may have affected the findings. First, distant metastases were defined based on imaging evidence, which was typically performed at the time of biochemical recurrence. However, triggers for imaging may vary between institutions. Given that approximately 80% of patients treated with EBRT+BT were contributed by centers that did not contribute patients receiving radical prostatectomy patients, we wonder whether the observed longer time to distant metastases in patients treated with EBRT+BT may be attributed to differential time to imaging among centers.
Ong WL, Koh TL, Millar J. Optimal Treatment for High-Risk Prostate Cancer. JAMA. 2018;320(4):404–405. doi:10.1001/jama.2018.6709
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