Background
Among men with localized high‐risk prostate cancer (PCa), patients who meet very high‐risk (VHR) criteria have been shown to experience worse outcomes after radical prostatectomy (RP) in a previous study. Variations of VHR criteria have been suggested to be prognostic in other single‐center cohorts, but multicenter outcomes validating VHR criteria have not been described. This study was designed to validate VHR criteria for identifying which PCa patients are at greatest risk for cancer progression.
Methods
Patients with high‐risk PCa undergoing RP (2005‐2015) at 3 tertiary centers were pooled. The outcomes of men with VHR PCa were compared with the outcomes of those who did not meet VHR criteria. The high‐risk criteria were a clinical stage of T3 to T4, a prostate‐specific antigen level > 20 ng/mL, or a biopsy Gleason grade sum of 8 to 10. The VHR criteria were multiple high‐risk features, >4 biopsy cores with a Gleason grade sum of 8 to 10, or primary Gleason grade pattern 5. Biochemical recurrence, metastasis (METS), and cancer‐specific mortality (CSM) were assessed with competing risks regressions. Overall mortality was assessed with Cox survival models.
Results
Among 1981 patients with high‐risk PCa, men with VHR PCa (n = 602) had adverse pathologic outcomes: 37% versus 25% for positive margins and 37% versus 15% for positive lymph nodes (P < .001 for both comparisons). Patients with VHR PCa also had higher adjusted hazard ratios for METS (2.78; 95% confidence interval [CI], 2.08‐3.72), CSM (6.77; 95% CI, 2.91‐15.7), and overall mortality (2.44; 95% CI, 1.56‐3.80; P < .001 for all comparisons).
Conclusions
In a validation study of patients who underwent treatment for high‐risk PCa, VHR criteria were strongly associated with adverse pathologic and oncologic outcomes.
Objective
To compare radical prostatectomy (RP) vs radiotherapy (RT) with androgen‐deprivation therapy (ADT) in the setting of patients with high‐risk and very high‐risk (VHR) prostate cancer who were deemed eligible for either therapy and made a treatment choice after consultation in a multidisciplinary prostate cancer clinic (MDPCC), and to compare the MDPCC patients’ outcomes to a matched Surveillance, Epidemiology and End Results (SEER) cohort.
Patients and methods
Prospectively collected, retrospective study comparing patients who underwent RP (231 patients) vs RT+ADT (73) from 2004 to 2013. Biochemical recurrence (BCR), local recurrence, distant metastasis failure, and overall survival (OS) were calculated for each treatment group overall and according to National Comprehensive Cancer Network risk strata. A propensity score matched comparison with a SEER cohort was performed for OS.
Results
There was no difference in local recurrence (hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.0–7.9; P = 0.06), distant metastasis failure (HR 2.5, 95% CI 0.8–7.8; P = 0.1) and OS (HR 1.35, 95% CI 0.4–4.8; P = 0.6) between patients undergoing RP vs RT+ADT. Patients treated via the MDPCC survived on average 16.9 months (95% CI 13.1–20.8) longer than those in the matched SEER cohort.
Conclusions
Long‐term outcomes appear similar amongst patients with high‐risk and VHR prostate cancer deemed eligible for either RP or RT, and treated after consultation in a MDPCC. Outcomes of the MDPCC patients were superior to those of the matched SEER cohort.
We demonstrated that patients with pathologic T2 tumors with PSM > 1 mm or a Gleason grade of tumor focus at the margin ≥ 4 are at elevated risk for BCR. However, this study suggests that patients with pT2 tumors with positive surgical margins have a relatively low risk of biochemical recurrence and adjuvant radiation may be over treating this sub population. The subsets at greatest risk for BCR may benefit from more frequent PSA monitoring to direct salvage therapies.
This prospective non-randomized study shows long-term differences in QoL domains after bilateral nerve-sparing RARP and brachytherapy. Differences in patient satisfaction should be further explored. These results could be used to counsel patients in the decision-making process.
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