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Original Investigation
July 2018

Association of Smoking Status With Recurrence, Metastasis, and Mortality Among Patients With Localized Prostate Cancer Undergoing Prostatectomy or Radiotherapy: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Urology, Medical University of Vienna, Vienna, Austria
  • 2Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
  • 3Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
  • 4Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
  • 5Department of Urology, Jikei University School of Medicine, Tokyo, Japan
  • 6Department of Urology, Weill Cornell Medical College, New York, New York
  • 7Department of Urology, University of Texas Southwestern Medical Center, Dallas
  • 8Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
JAMA Oncol. 2018;4(7):953-961. doi:10.1001/jamaoncol.2018.1071
Key Points

Question  What is the association of smoking with oncologic outcomes among patients undergoing radical prostatectomy or radiotherapy for localized prostate cancer?

Findings  In this systematic review and meta-analysis that included 11 studies with 22 549 patients with prostate cancer undergoing primary radical prostatectomy or radiotherapy, current smokers had a significantly higher risk of biochemical recurrence, metastasis, and cancer-specific mortality.

Meaning  These results should encourage radiation oncologists and urologists to counsel patients on smoking cessation, given the risk of poorer oncologic outcomes associated with smoking.


Importance  Studies investigating the association of cigarette smoking with prostate cancer incidence and outcomes have revealed controversial results.

Objective  To systematically review and analyze the association of smoking status with biochemical recurrence, metastasis, and cancer-specific mortality among patients with localized prostate cancer undergoing primary radical prostatectomy or radiotherapy.

Data Sources  A systematic search of original articles published between January 2000 and March 2017 was performed using PubMed, MEDLINE, Embase, and Cochrane Library databases in March 2017.

Study Selection  Observational studies reporting Cox proportional hazards regression or logistic regression analyses were independently screened.

Data Extraction and Synthesis  This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. Available multivariable hazard ratios (HRs) and corresponding 95% CIs were included in quantitative analysis. A risk-of-bias assessment was completed for nonrandomized studies.

Main Outcomes and Measures  Prespecified outcomes of interest were biochemical recurrence, metastasis, and cancer-specific mortality.

Results  A total of 5157 reports were identified, of which 16 articles were selected for qualitative analysis and 11 articles were selected for quantitative analysis. All included studies were observational and nonrandomized and comprised a total of 22 549 patients. Overall, 4202 patients (18.6%) were current smokers. The overall median follow-up was 72 months. Current smokers had a statistically significantly higher risk of biochemical recurrence (HR, 1.40; 95% CI, 1.18-1.66; P < .001 [10 studies]), as did former smokers (HR, 1.19; 95% CI, 1.09-1.30; P < .001 [7 studies]). Current smokers were also at a higher risk of metastasis (HR, 2.51; 95% CI, 1.80-3.51; P < .001 [3 studies]) and cancer-specific mortality (HR, 1.89; 95% CI, 1.37-2.60; P < .001 [5 studies]), whereas former smokers were not (metastasis: HR, 1.61; 95% CI, 0.65-3.97; P = .31 [2 studies]; cancer-specific mortality: HR, 1.05; 95% CI, 0.81-1.37; P = .70 [4 studies]).

Conclusions and Relevance  Current smokers at the time of primary curative treatment for localized prostate cancer are at higher risk of experiencing biochemical recurrence, metastasis, and cancer-specific mortality.