Brachytherapy-Based Radiotherapy and Radical Prostatectomy Are Associated With Similar Survival in High-Risk Localized Prostate Cancer

Abstract

Purpose There are no randomized trials to guide treatment decisions between radiotherapeutic and surgical options for patients with high-risk localized prostate cancer. Comparative studies have been limited by their ability to match patients on the basis of pretreatment prognostic variables and to adjust for the cancer-related, medical, and socioeconomic differences between patients who choose radiotherapeutic or surgical approaches. Methods We analyzed the outcome of all patients in the National Cancer Database with high-risk, clinically localized prostate cancer with complete prognostic data who were treated with either radical prostatectomy (RP), external beam radiotherapy (EBRT) combined with androgen deprivation (AD), or EBRT plus brachytherapy with or without AD. Inverse probability of treatment weighting was used to adjust for covariable imbalance among treatment groups. The weighted time-dependent Cox proportional hazards model was then used to estimate the effects of treatment groups on survival, accounting for differential treatment initiation times. A predictive model of pathologic nodal (pLN) status was built using prostate-specific antigen level, Gleason score, and clinical T stage; predicted pLN status was used to repeat the inverse probability of treatment weighting and time-dependent Cox proportional hazards model. Results A total of 42,765 patients were analyzed. There was no statistically significant difference in survival between RP and EBRT plus brachytherapy with or without AD (hazard ratio [HR], 1.17; 95% CI, 0.88 to 1.55). However, EBRT plus AD was associated with higher mortality than RP (HR, 1.53; 95% CI, 1.22 to 1.92). Adjustment for predicted pLN status did not yield statistically different results. A sensitivity analysis showed that EBRT plus AD ≥ 7920 cGy narrowed the difference, but a significantly higher mortality remained (HR, 1.33; 95% CI, 1.05 to 1.68). Conclusion After comprehensively adjusting for imbalances in prostate cancer prognostic factors, other medical conditions, and socioeconomic factors, this analysis showed no statistical difference in survival between patients treated with RP versus EBRT plus brachytherapy with or without AD. EBRT plus AD was associated with lower survival.

Investigating the role of constrained CVT and CVT in HIPO inverse planning for HDR brachytherapy of prostate cancer

“…This was for 11 catheters (median value, range 7-20) the case, when compared to final plans generated using the default initialization of HIPO. On the other hand, the HIPO CVT_adaptive plans differed in ten catheter positions (median value, range [6][7][8][9][10][11][12][13][14][15][16][17][18], when compared to corresponding final HIPO default_adaptive plans.…”

“…Prostate HDR brachytherapy (HDRBT) has been established as a significant treatment method for the radiotherapy of prostate cancer (PCA) in a variety of protocols. [1][2][3][4] HDRBT is often used either as a local dose escalation technique in a boost set-up in combination with external beam radiotherapy (EBRT) for intermediate-and high-risk-PCA [5][6][7][8] or as monotherapy for localized prostate cancer (low-intermediate risk and selective high-risk PCA cases). [9][10][11][12][13][14][15] During the last two decades, significant innovations such as improved ultrasound (U/S) image quality, high resolution three-dimensional (3D) U/S volume acquisition, and catheter reconstruction on live U/S-imaging have been achieved in the field of 3D intraoperative ultrasound HDR-BT for PCA.…”

Impact of Age and Life-expectancy on Treatment Receipt in High-risk Prostate Cancer

“…However, only one-fifth of CaPSURE patients had clinically significant cancer. Although the most recent study showed a significant benefit of radical prostatectomy over radiotherapy among young (age ≤65) men [7], several other studies found that radiation therapy was as effective as radical prostatectomy for high-risk cancer treatment [8,9]. Despite the debate over the benefit of these definitive treatments, whether there is a treatment preference among older men is not well documented.…”

Brachytherapy‐based radiotherapy with androgen deprivation for management of high‐risk prostate cancer – time to reverse the declining trend?

“…In a population‐based retrospective study involving 42 576 men in the National Cancer Database, Ennis et al. reported that there were no differences in overall survival between men with high‐risk PCa treated with RP and those treated with EBRT + BT plus ADT, but men treated with EBRT plus ADT had significantly lower overall survival. In a separate retrospective study pooling 1 809 men with Gleason 9–10 PCa across 12 tertiary institutions in the USA and Norway, Kishan et al.…”

“…Among the men who opt for RT, not all are suitable for BT boost because of pre‐existing urethral strictures, significant BOO, previous TURP, or large prostate volume; these men will be more appropriately treated with EBRT alone. However, with an increasing body of evidence supporting improved oncological outcomes with EBRT + BT over EBRT alone , the addition of BT boost, in the form of HDR or LDR therapy, to EBRT should be considered in all men with high‐risk PCa who opt for RT. In fact, it may be considered suboptimal care to not refer these patients for discussion and evaluation for BT boost, particularly the younger cohort.…”