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AUA 2019

AUA 2019: 18-Year Prostate Cancer-Specific Mortality after Prostatectomy, Brachytherapy, External Beam Radiation Therapy, Hormonal Therapy, or Monitoring for Localized Prostate Cancer

Chicago, IL (UroToday.com) The comparative effectiveness of prostate cancer treatments, particularly surgery and various radiotherapy approaches, remains both a high priority, according to the Institute of Medicine, and controversial. To date, there are limited randomized data to assess this question. Two historical trials performed by the Uro-Oncology Research Group and the Japanese Study Group for Locally Advanced Prostate Cancer demonstrated improved outcomes in patients treated with surgery through their limitations (including insufficient follow-up and the inclusion of only clinically detected prostate cancer) have limited their application to current practice. Two more contemporaneous studies, the ProtecT trial1 and Lennernas et al.2, demonstrated no difference in survival between radiotherapy and surgical approaches although both studies are significantly underpowered for this outcome.

While other studies have examined alternative outcomes, including biochemical recurrence, these outcomes are not sufficiently robust to provide meaningful comparisons between the treatment modalities. Thus, many have relied upon non-randomized data to inform the discussion of the relative merits of prostate cancer treatments. One of the most robust non-randomized data sources is the CaPSURE registry, owing to its generalizable nature due to inclusion of academic and community practices, as well as the granular data which it offers. Previously, Cooperberg et al. utilized these data to compare outcomes for patients treated with surgery, radiotherapy, or ADT3. In a podium presentation at the American Urologic Association Annual Meeting, Dr. Herlemann and colleagues present the results of an updated analysis of these data with 18-year prostate cancer specific mortality findings.

Utilizing the Cancer of the Prostate Strategic Urologic Research Endeavour (CaPSURE) registry, the authors identified 9774 men with localized prostate cancer who underwent radical prostatectomy, primary ADT, external beam radiotherapy, brachytherapy, or active surveillance/watchful waiting. They risk-stratified patients on the basis of the Kattan nomogram and the Cancer of the Prostate Risk Assessment (CAPRA) score and performed multivariable analysis adjusting for patient age and case-mix.

The majority of their cohort underwent radical prostatectomy (5235, 54%), with 1138 (12%) receiving brachytherapy, 1307 (13%) receiving EBRT, 1262 (13%) receiving primary ADT, and 832 (9%) receiving AS/WW. 319 men (3%) died of prostate cancer during the 18-year follow-up period with a median time to PCSM was 70 months (IQR 42-108 months). After adjustment for prostate cancer risk factors using the CAPRA score, patients who underwent brachytherapy (HR 1.58, 95% CI 1.04-2.40), external beam radiotherapy (HR 2.08, 95% CI 1.54-2.82), primary ADT (HR 3.01, 95% CI 2.22-4.10), and AS/WW (HR 2.07, 95% CI 1.33-3.21) were more likely to die of prostate cancer than those who received radical prostatectomy.

The difference between treatment approaches was significantly modified by underlying prostate cancer risk – among patients with low-risk disease, there were no significant differences in survival between any strategy and the differential benefit of radical prostatectomy was greatest in patients with high-risk disease.
AUA2019 18 Year Prostate Cancer Specific Mortality 2

While there are inevitable selection biases with these data, they support the broad uptake of active surveillance in men with low-risk prostate cancer (as utilization in the US lags well behind other nations) and an increasing role for surgical management of high-risk disease.

 

Presented by: Annika Herlemann, MD, Assistant Profesor, University of California San Francisco
Co-authors: Janet E. Cowan, Samuel L. Washington III, Jeanette M. Broering, Peter R. Carroll, Matthew R. Cooperberg

Written by: Christopher J.D. Wallis, Urology Resident, University of Toronto, @WallisCJD at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois

References
  1. Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. The New England journal of medicine 2016.The New England journal of medicine 2016.
  2. Lennernas B, Majumder K, Damber JE, et al. Radical prostatectomy versus high-dose irradiation in localized/locally advanced prostate cancer: A Swedish multicenter randomized trial with patient-reported outcomes. Acta Oncol 2015; 54(6): 875-81.Acta Oncol 2015; 54(6): 875-81.
  3. Cooperberg MR, Vickers AJ, Broering JM, Carroll PR. Comparative risk-adjusted mortality outcomes after primary surgery, radiotherapy, or androgen-deprivation therapy for localized prostate cancer. Cancer 2010; 116(22): 5226-34.