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The management of patients with high-risk localized prostate cancer typically requires multimodality therapy. However, the optimal approach remains undefined.
To address this issue, investigators conducted an international, retrospective cohort study involving 1809 men treated for high-risk prostate cancer (Gleason score, 9–10) between 2000 and 2013. Of these patients, 639 underwent radical prostatectomy (RP), 734 underwent external beam radiotherapy (EBRT), and 436 underwent EBRT plus brachytherapy boost (EBRT+BT). Most EBRT and EBRT+BT patients received androgen deprivation therapy (ADT; 89.5% and 92.4%, respectively), but EBRT+BT patients had a shorter median duration of ADT than did EBRT patients (12.0 vs. 21.9 months; P<0.001).
The 5-year incidence rates of prostate cancer–specific mortality (the primary outcome) for RP, EBRT, and EBRT+BT were 10%, 11%, and 3%, respectively; EBRT+BT was associated with a significantly reduced risk for prostate cancer–specific mortality compared with RP or EBRT (P<0.001). Adjusted 5-year incidence rates of distant metastases for RP, EBRT, and EBRT+BT were 24%, 24%, and 8%, respectively. No significant differences in prostate cancer–specific mortality, distant metastasis, or all-cause mortality were found between EBRT and RP.
Kishan AU et al. Radical prostatectomy, external beam radiotherapy, or external beam radiotherapy with brachytherapy boost and disease progression and mortality in patients with Gleason score 9–10 prostate cancer. JAMA 2018 Mar 6; 319:896. (https://doi.org/10.1001/jama.2018.0587)
Comment
Given the retrospective design of this study, the authors acknowledge that it cannot adequately capture comorbidity issues that complicate comparisons between EBRT and EBRT+BT. In addition, toxicity and patient-reported outcomes were not available. Despite these limitations, the results are provocative and may inform practice, as prospective testing in this narrow disease subset will never be conducted.