A Comparison between Low Dose-Rate Brachytherapy +/- Androgen Deprivation, External Beam Radiotherapy +/- Androgen Deprivation, and Radical Prostatectomy +/- Adjuvant or Salvage Radiotherapy for High-Risk Prostate Cancer

Publication date: Available online 18 December 2016
Source:International Journal of Radiation Oncology*Biology*Physics
Author(s): Jay P. Ciezki, Michael Weller, Chandana A. Reddy, Jeffrey Kittel, Harguneet Singh, Rahul Tendulkar, Kevin L. Stephans, James Ulchaker, Kenneth Angermeier, Andrew Stephenson, Steven Campbell, Georges-Pascal Haber, Eric A. Klein
PurposeWe compare the efficacy and toxicity among the three major modalities available used to treat high-risk prostate cancer (HRCaP).Methods and MaterialsFrom 1996-2012, 2557 HRCaP patients were treated: 734 external beam radiation (EBRT) +/- androgen deprivation therapy (ADT), 515 low-dose-rate prostate brachytherapy (LDR) +/- ADT, and 1308 radical prostatectomy (RP) +/- EBRT. Biochemical relapse-free survival (bRFS), clinical relapse-free survival (cRFS), and prostate cancer-specific mortality (PCSM) were assessed. Toxicity was assessed using the Common Terminology Criteria for Adverse Events, version 4.03 (CTCAE v4.03). The log-rank test compared bRFS and cRFS among the modalities, and Cox regression identified factors associated with bRFS and cRFS. Gray's test compared differences in late toxicity and PSCM among the modalities. Competing risk regression identified factors associated with PCSM.ResultsThe median follow-up and age were 63.5 months and 65 years, respectively. The bRFS at 5 and 10 years, respectively, was 74% and 53% for EBRT, 74% and 52% for LDR, and 65% and 47% for RP (p=0.0001). The cRFS at 5 and 10 years, respectively, was 85% and 73% for EBRT, 90% and 76% for LDR, and 89% and 75% for RP (p=0.121). The PCSM at 5 and 10 years, respectively, was 5.3% and 11.2% for EBRT, 3.2% and 3.6% for LDR, and 2.8% and 6.8% for RP (p=0.0004). The 10-year cumulative incidence of > grade 3 genitourinary toxicity was 8.1% for EBRT, 7.2% for LDR, and 16.4% for RP (p<0.0001). The 10-year cumulative incidence of > grade 3 gastrointestinal toxicity was 4.6% for EBRT, 1.1% for LDR, 1.0% for RP (p<0.0001).ConclusionHRCaP treated with EBRT, LDR, or RP yields efficacy showing better bRFS for LDR and EBRT relative to RP, equivalence for cRFS, and a PCSM advantage of LDR and RP over EBRT. The toxicity is lowest for LDR.

Teaser

There is no level I evidence defining a standard of care for patients with high-risk prostate cancer. Clinical trials comparing treatment variations within a modality exist but none compare outcomes among modalities. We present an inception cohort study in which we compare efficacy and toxicity among the three major therapeutic modalities for high-risk prostate cancer: radical prostatectomy plus/minus adjuvant or salvage radiotherapy, external beam radiotherapy plus/minus androgen deprivation, and low-dose-rate prostate brachytherapy plus/minus androgen deprivation therapy.


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