MADRID, SPAIN (UroToday.com) - Dr. Alberto Bossi, a radiation-oncologist, discussed this very important topic of the toxicities of multimodality treatment—surgery in context with radiotherapy.
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He opened his presentation by stating that to be fair and unbiased he would use non-radiation oncology literature to present his arguments. He made the argument that toxicities and complications presentation should be based on measurable health-related quality of life domains and patient-reported prospective evaluation.
He then presented data from Sanda, NEJM 2008 trial on “Quality of life and satisfaction outcome among prostate-cancer survivors.” He praised this study for having a good number of patients with surgery, EBRT, and BT arms. However, he criticized the facts that surgical patients were younger, had less co-existing illness, lower initial PSA, lower biopsy Gleason score, and D’Amico Risk grouping. Thus, toxicities from radiotherapies need to be judged on patient characteristics too. From SANDA trial, he pointed out that patients were bothered about sexual function, vitality, and urinary symptoms while bowel or rectal function was less of a bother to patients. The partners were bothered by sexual function and vitality and not as much about urinary issues or bowel or rectal function.
Dr. Bossi then highlighted the Punnen, Eur Urol 2014 study on “Long-term health-related quality of life after primary treatment for localized prostate cancer: Results from the CaPSURE Registry.” He emphasized that the surgical arms started out pretreatment with higher adjusted physical function than radiotherapy arms due to the fact that surgical patients generally had less comorbid conditions. However, following treatment, with respect to urinary functions, surgical arms had lower adjusted urinary functional scores over radiotherapy arms. Similarly following treatment, surgical arms had lower adjusted sexual function scores.
Surgery for high-risk prostate cancer is a multimodality approach. About 80% of these patients receive adjuvant or salvage radiotherapy. He highlighted from the Suardi, et al. BJUI 2012 study that urinary continence is worse in non-nerve sparing radical prostatectomy and high-risk patients. The addition of adjuvant RT only worsens continence rates (Suardi, et al., Eur Urol 2014). He pointed out a recent report by Jarosek et al, Eur Urol 2015 that RP +EBRT has the worst incidence of any urinary adverse event, followed by RP alone, followed by other radiotherapies alone. Dr. Bossi pointed out that radiotherapy arms had the least urinary symptoms. However, in the context of radical prostatectomy, these adverse urinary symptoms were worse.
To answer the concern of secondary malignancies subsequent to radiotherapies, he pointed out that for a 70-year-old man, “the chances of dying from a second cancer due to EBRT at 15 years is probably less than the risk of dying after a radical prostatectomy (0.66%) within 30 days.”
So coming back to the question, ‘is radiotherapy really less toxic than surgery?’ There is no randomized data between surgery and radiotherapy to support one way or the other. He pointed out that radiation oncologists are using advanced methodology of delivering radiotherapy, just as surgeons are using better tools. “We are not using primitive radiotherapy anymore.”
Presented by Alberto Bossi at the 30th Annual European Association of Urology (EAU) Congress - March 20 - 24, 2015 - IFEMA - Feria de Madrid - Madrid, Spain
Institut Gustave Roussy, Villejuif
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Reported by Mohammed Haseebuddin, MD, medical writer for UroToday.com