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Original Investigation
November 15, 2018

Surgery vs Radiotherapy in the Management of Biopsy Gleason Score 9-10 Prostate Cancer and the Risk of Mortality

Author Affiliations
  • 1Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
  • 2Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
  • 3Department of Statistics, University of Connecticut, Storrs
  • 4Department of Computer Science and Statistics, University of Rhode Island, Kingston
  • 5Chicago Prostate Cancer Center, Westmont, Illinois
  • 6Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Oncol. 2019;5(2):213-220. doi:10.1001/jamaoncol.2018.4836
Key Points

Question  Can treatment with radical prostatectomy, adjuvant external beam radiotherapy, and androgen deprivation therapy (termed MaxRP) or external beam radiotherapy, brachytherapy, and androgen deprivation therapy (termed MaxRT) in men with Gleason score 9-10 prostate cancer provide similar survival outcomes?

Findings  Among 639 men, this cohort study found no significant difference after MaxRP or MaxRT in prostate cancer–specific and all-cause death risk, with plausibility indexes for equivalence of 76.75% for prostate cancer–specific mortality risk and 77.97% for all-cause mortality risk.

Meaning  It is plausible that treatment with MaxRP or MaxRT for men with Gleason score 9-10 prostate cancer provides equivalent survival outcomes.

Abstract

Importance  It is unknown how treatment with radical prostatectomy (RP) and adjuvant external beam radiotherapy (EBRT), androgen deprivation therapy (ADT), or both (termed MaxRP) compares with treatment with EBRT, brachytherapy, and ADT (termed MaxRT).

Objective  To investigate whether treatment of Gleason score 9-10 prostate cancer with MaxRP vs MaxRT was associated with prostate cancer–specific mortality (PCSM) and all-cause mortality (ACM) risk.

Design, Setting, and Participants  The study cohort comprised 639 men with clinical T1-4,N0M0 biopsy Gleason score 9-10 prostate cancer. Between February 6, 1992, and April 26, 2013, a total of 80 men were consecutively treated with MaxRT at the Chicago Prostate Cancer Center, and 559 men were consecutively treated with RP and pelvic lymph node dissection at the Martini-Klinik Prostate Cancer Center. Follow-up started on the day of prostate EBRT or RP and concluded on October 27, 2017.

Exposures  Of the 559 men managed with RP and pelvic lymph node dissection, 88 (15.7%) received adjuvant EBRT, 49 (8.8%) received ADT, and 50 (8.9%) received both.

Main Outcomes and Measures  Treatment propensity score–adjusted risk of PCSM and ACM and the likelihood of equivalence of these risks between treatments using a plausibility index.

Results  The cohort included 639 men, with a mean (SD) age of 65.83 (6.52) years. After median follow-ups of 5.51 years (interquartile range, 2.19-6.95 years) among 80 men treated with MaxRT and 4.78 years (interquartile range, 4.01-6.05 years) among 559 men treated with RP-containing treatments, 161 men had died, 106 (65.8%) from prostate cancer. There was no significant difference in the risk of PCSM (adjusted hazard ratio, 1.33; 95% CI, 0.49-3.64; P = .58) and ACM (adjusted hazard ratio, 0.80; 95% CI, 0.36-1.81; P = .60) when comparing men who underwent MaxRP vs MaxRT, with plausibility indexes for equivalence of 76.75% for the end point of the risk of PCSM and 77.97% for the end point of the risk of ACM. Plausibility indexes for all other treatment comparisons were less than 63%.

Conclusions and Relevance  Results of this study suggest that it is plausible that treatment with MaxRP or MaxRT for men with biopsy Gleason score 9-10 prostate cancer can lead to equivalent risk of PCSM and ACM.

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