Top Line: Specialty bias rarely shows itself more than in opinions on the best definitive treatment for prostate cancer.
The Study: Fifteen year outcomes for the randomized ProtecT trial showed a relatively low rate of prostate cancer specific mortality with surgery, radiation, or active surveillance for localized disease with no significant difference between arms. But we can’t let level I evidence hold us back. A mostly prospective US registry of 11,864 men receiving primary treatment with radical prostatectomy (53%), brachytherapy (14%), external beam radiation (12%), androgen deprivation (ADT) monotherapy (13%), or surveillance/observation (9%) for localized prostate cancer indicates a significant prostate cancer mortality advantage with surgery when adjusting for risk group: brachy (HR 1.57), external beam (HR 1.55), ADT (HR 2.36), and surveillance (HR 1.76). However, RP patients were significantly younger with fewer comorbidities, lower grade disease, and lower risk disease. In fact, just 7.8% of RP patients had CAPRA high risk disease compared to 25% of EBRT patients. In other words, there were obvious reasons why patients were selected for surgery versus other therapies that can’t be accounted for in the dataset. Other criticisms include the fact that roughly one-third of men receiving radiation for high-risk disease received no ADT, and the median recorded radiation dose was not dose-escalated (accrual dated back to 1995). On the latter point, the authors do make a half-hearted concession: “Improvements in radiation dose and technique over the past decades have evolved, potentially driving better outcomes today although it has been shown that these largely improve biochemical outcomes and not necessarily prostate cancer-specific or overall survival and are relatively unlikely to explain the magnitude of differences we observe.”
TBL: The authors conclude that their findings support a larger role for surgery for high risk disease, though the caveats above likely ensure the multidisciplinary debate will continue in full force. | Herlemann, Eur Urol 2023
The Study: Fifteen year outcomes for the randomized ProtecT trial showed a relatively low rate of prostate cancer specific mortality with surgery, radiation, or active surveillance for localized disease with no significant difference between arms. But we can’t let level I evidence hold us back. A mostly prospective US registry of 11,864 men receiving primary treatment with radical prostatectomy (53%), brachytherapy (14%), external beam radiation (12%), androgen deprivation (ADT) monotherapy (13%), or surveillance/observation (9%) for localized prostate cancer indicates a significant prostate cancer mortality advantage with surgery when adjusting for risk group: brachy (HR 1.57), external beam (HR 1.55), ADT (HR 2.36), and surveillance (HR 1.76). However, RP patients were significantly younger with fewer comorbidities, lower grade disease, and lower risk disease. In fact, just 7.8% of RP patients had CAPRA high risk disease compared to 25% of EBRT patients. In other words, there were obvious reasons why patients were selected for surgery versus other therapies that can’t be accounted for in the dataset. Other criticisms include the fact that roughly one-third of men receiving radiation for high-risk disease received no ADT, and the median recorded radiation dose was not dose-escalated (accrual dated back to 1995). On the latter point, the authors do make a half-hearted concession: “Improvements in radiation dose and technique over the past decades have evolved, potentially driving better outcomes today although it has been shown that these largely improve biochemical outcomes and not necessarily prostate cancer-specific or overall survival and are relatively unlikely to explain the magnitude of differences we observe.”
TBL: The authors conclude that their findings support a larger role for surgery for high risk disease, though the caveats above likely ensure the multidisciplinary debate will continue in full force. | Herlemann, Eur Urol 2023