Outcome Equivalency Between Radical Prostatectomy and Prostate Radiotherapy

Selected by Pietro Cazzola

Cancro prostataThat prostate cancer outcomes are essentially equivalent between radical prostatectomy (RP) and prostate radiotherapy (RT) is a commonly accepted tenant in the modern management of localized prostate cancer. Clinicians often come to this viewpoint from evidence that often employs shifting failure definitions, which may be confounded by androgen deprivation therapy as well as intrinsic differences in the selection of these modalities. With the assumption of oncologic parity, the net result is that therapeutic choice is frequently driven by other factors, which include anticipated toxicity profiles, age, and patient preference, notwithstanding the specialty affiliation or possible financial incentives held by the treating provider.
In this context, we read with enthusiasm an article published in European Urology by Lee and colleagues from the Cleveland Clinic who compare rates of prostate cancer–specific mortality (PCSM) following biochemical recurrence (BCR) between men treated with RP and RT.1 In their analysis, the authors derived 5-year progression-free probability from three commonly utilized treatment-specific nomograms applied to nearly 14,000 men treated with RP, brachytherapy (BT), or external beam radiation therapy (EBRT) at two large institutions, and subsequently stratified PCSM from these estimates. Patients treated with EBRT displayed higher estimates of PCSM at all BCR risk groupings compared with men treated with RP (HR, 1.5; 95% CI, 1.1–2.0; P = .006), while those treated with BT did not appear significantly different from those who underwent RP.
Many of the aforementioned issues that muddy the waters in a comparison between modalities do indeed apply here: patients treated with RP were considerably younger and had lower-risk disease than those receiving EBRT, factors which may be incompletely accounted for in the progression-free survival nomograms employed. Moreover, the pursuit of surgical treatment in a majority of low-grade (70% Gleason ≤6) and low-stage (73% T1c) cancers reflects a now unfashionable trend. Nonetheless, a compelling conceptual argument that cancer-specific mortality following BCR may be inferior for men treated with EBRT compared with RP (and BT) is offered in this report. We are left to speculate—as do the authors—whether these differences derive from local control or timely secondary intervention that may be afforded by the enriched pathologic and biochemical information generated through surgical treatment.