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Thread: (F) Treatment Decisions Comparisons Trends

  1. #91
    Radical Prostatectomy or Watchful Waiting in Prostate Cancer — 29-Year Follow-up



    Radical prostatectomy reduces mortality among men with clinically detected localized prostate cancer, but evidence from randomized trials with long-term follow-up is sparse.

    We randomly assigned 695 men with localized prostate cancer to watchful waiting or radical prostatectomy from October 1989 through February 1999 and collected follow-up data through 2017. Cumulative incidence and relative risks with 95% confidence intervals for death from any cause, death from prostate cancer, and metastasis were estimated in intention-to-treat and per-protocol analyses, and numbers of years of life gained were estimated. We evaluated the prognostic value of histopathological measures with a Cox proportional-hazards model.

    By December 31, 2017, a total of 261 of the 347 men in the radical-prostatectomy group and 292 of the 348 men in the watchful-waiting group had died; 71 deaths in the radical-prostatectomy group and 110 in the watchful-waiting group were due to prostate cancer (relative risk, 0.55; 95% confidence interval [CI], 0.41 to 0.74; P<0.001; absolute difference in risk, 11.7 percentage points; 95% CI, 5.2 to 18.2). The number needed to treat to avert one death from any cause was 8.4. At 23 years, a mean of 2.9 extra years of life were gained with radical prostatectomy. Among the men who underwent radical prostatectomy, extracapsular extension was associated with a risk of death from prostate cancer that was 5 times as high as that among men without extracapsular extension, and a Gleason score higher than 7 was associated with a risk that was 10 times as high as that with a score of 6 or lower (scores range from 2 to 10, with higher scores indicating more aggressive cancer).

    Men with clinically detected, localized prostate cancer and a long life expectancy benefited from radical prostatectomy, with a mean of 2.9 years of life gained. A high Gleason score and the presence of extracapsular extension in the radical prostatectomy specimens were highly predictive of death from prostate cancer.

  2. #92
    Current controversies on the role of lymphadenectomy for prostate cancer



    Lymph node dissection is part of the standard treatment protocol for various cancers, but its role in prostate cancer has been debatable for some time. Pelvic lymphadenectomy has been shown to better help stage prostate cancer patients, but has yet to be definitively proven to be of any benefit for survival. Various templates for lymph node dissections exist, and though some national guidelines have endorsed an extended pelvic node dissection, the choice of template is still controversial. Pelvic lymphadenectomy may lead to a slightly higher rate complications and operative time, and their use must be judiciously applied to patients with a high enough risk of lymph node involvement. We present a comprehensive review of the literature regarding the benefits and harms of lymph node dissection in prostate cancer.

  3. #93
    Evaluation of Cancer Specific Mortality with Surgery versus Radiation as Primary Therapy for Localized High Grade Prostate Cancer in Men Younger Than 60 Years



    The optimal primary treatment of localized high grade prostate cancer in younger men remains controversial. The objective of this project was to compare the impact of initial radical prostatectomy vs radiation therapy on survival outcomes in young men less than 60 years old with high grade prostate cancer.

    We retrospectively analyzed the records of men younger than 60 years in the SEER (Surveillance, Epidemiology and End Results) database who underwent initial surgery or radiation therapy of high grade (Gleason score 8 or greater) localized (N0M0 TNM stage) prostate cancer from 2004 to 2012. Univariate and multivariate Cox proportional hazards regression models were used to examine prostate cancer specific and overall mortality.

    A total of 2,228 men were identified, of whom 1,459 (65.5%) underwent initial surgery and had a median followup of 43 months and 769 (34.5%) underwent initial external beam radiation therapy with or without brachytherapy and had a median followup of 44 months. On multivariate analysis initial treatment with surgery was associated with improved prostate cancer specific and overall mortality compared with initial radiation treatment (HR 0.37, 95% CI 0.19-0.74, p = 0.005 vs HR 0.41, 95% CI 0.24-0.70, p = 0.001) when controlling for age, biopsy Gleason score, T stage and prostate specific antigen.

    Our data showed significant survival differences in young men treated initially with surgery vs external beam radiation therapy of high grade prostate cancer. Future prospective randomized trials are needed to confirm the long-term outcomes of these treatment approaches.
    Note that SBRT is often omitted from these RT vs RP reviews; I'm not sure why. Perhaps it's the number of treated men.

    I managed to get the Full Text. No mention is made of SBRT.

    Explanations for improved survival outcomes with initial surgery for high-grade prostate cancer are likely multi-factorial. First, pathologic examination of resection specimen allows for more accurate evaluation of the extent of cancer and appropriate selection of men requiring adjuvant therapy, which has been shown to improve metastasis-free and overall survival.23, 24 Second, in localized disease, surgery reduces tumor volume and helps establish local control, which can improve response to systemic therapies.25 Resection has also been thought to reduce the proportion of hormone resistant cells.26 Third, PSA is generally detectable after surgery and can be treated with adjuvant therapies sooner than RT, as discontinuation of concurrent ADT results in an initial PSA rebound, making it more challenging to detect biochemical recurrence.23, 27

    This study, flagged by Forum Brother ASAdvocate, reached a different conclusion:

    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 [2018, Full Text]



    Importance The optimal treatment for Gleason score 9-10 prostate cancer is unknown.

    Objective To compare clinical outcomes of patients with Gleason score 9-10 prostate cancer after definitive treatment.

    Design, Setting, and Participants Retrospective cohort study in 12 tertiary centers (11 in the United States, 1 in Norway), with 1809 patients treated between 2000 and 2013.

    Exposures Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy, or EBRT plus brachytherapy boost (EBRT+BT) with androgen deprivation therapy.

    Main Outcomes and Measures The primary outcome was prostate cancer–specific mortality; distant metastasis-free survival and overall survival were secondary outcomes.

    Results Of 1809 men, 639 underwent RP, 734 EBRT, and 436 EBRT+BT. Median ages were 61, 67.7, and 67.5 years; median follow-up was 4.2, 5.1, and 6.3 years, respectively. By 10 years, 91 RP, 186 EBRT, and 90 EBRT+BT patients had died. Adjusted 5-year prostate cancer–specific mortality rates were RP, 12% (95% CI, 8%-17%); EBRT, 13% (95% CI, 8%-19%); and EBRT+BT, 3% (95% CI, 1%-5%). EBRT+BT was associated with significantly lower prostate cancer–specific mortality than either RP or EBRT (cause-specific HRs of 0.38 [95% CI, 0.21-0.68] and 0.41 [95% CI, 0.24-0.71]). Adjusted 5-year incidence rates of distant metastasis were RP, 24% (95% CI, 19%-30%); EBRT, 24% (95% CI, 20%-28%); and EBRT+BT, 8% (95% CI, 5%-11%). EBRT+BT was associated with a significantly lower rate of distant metastasis (propensity-score-adjusted cause-specific HRs of 0.27 [95% CI, 0.17-0.43] for RP and 0.30 [95% CI, 0.19-0.47] for EBRT). Adjusted 7.5-year all-cause mortality rates were RP, 17% (95% CI, 11%-23%); EBRT, 18% (95% CI, 14%-24%); and EBRT+BT, 10% (95% CI, 7%-13%). Within the first 7.5 years of follow-up, EBRT+BT was associated with significantly lower all-cause mortality (cause-specific HRs of 0.66 [95% CI, 0.46-0.96] for RP and 0.61 [95% CI, 0.45-0.84] for EBRT). After the first 7.5 years, the corresponding HRs were 1.16 (95% CI, 0.70-1.92) and 0.87 (95% CI, 0.57-1.32). No significant differences in prostate cancer–specific mortality, distant metastasis, or all-cause mortality (≤7.5 and >7.5 years) were found between men treated with EBRT or RP (cause-specific HRs of 0.92 [95% CI, 0.67-1.26], 0.90 [95% CI, 0.70-1.14], 1.07 [95% CI, 0.80-1.44], and 1.34 [95% CI, 0.85-2.11]).

    Conclusions and Relevance Among patients with Gleason score 9-10 prostate cancer, treatment with EBRT+BT with androgen deprivation therapy was associated with significantly better prostate cancer–specific mortality and longer time to distant metastasis compared with EBRT with androgen deprivation therapy or with RP.
    Last edited by DjinTonic; 12-28-2018 at 02:29 PM.

  4. #94
    New Prostate Cancer Targets for Diagnosis, Imaging, and Therapy: Focus on Prostate-Specific Membrane Antigen
    [2018, Full Text]

    New Prostate Cancer Targets for Diagnosis, Imaging, and Therapy: Focus on Prostate-Specific Membrane Antigen


    The rising incidence rate of the cancer in the prostate gland has increased the demand for improved diagnostic, imaging, and therapeutic approaches. Prostate-specific membrane antigen (PSMA), with folate hydrolase and carboxypeptidase and, internalization activities, is highly expressed in the epithelial cells of the prostate gland and is strongly upregulated in prostatic adenocarcinoma, with elevated expression correlating with, metastasis, progression, and androgen independence. Recently, PSMA has been an active target of investigation by several approaches, including the successful utilization of small molecule inhibitors, RNA aptamer conjugates, PSMA-based immunotherapy, and PSMA-targeted prodrug therapy. Future investigations of PSMA in prostate cancer (PCa) should focus in particular on its intracellular activities and functions. The objective of this contribution is to review the current role of PSMA as a marker for PCa diagnosis, imaging, and therapy.

  5. #95
    Should we involve patients more actively? Perspectives of the multidisciplinary team on shared decision-making for older patients with metastatic castration-resistant prostate cancer



    To evaluate perspectives of the multidisciplinary team concerning shared decision-making (SDM) in treatment decisions for older patients with metastatic castration-resistant prostate cancer (mCRPC).

    Materials and Methods
    A survey among Dutch healthcare providers was conducted to assess healthcare providers' perspectives on patient involvement in decision-making and the value of a decision aid (DA) in the decision-making process. Treatment recommendations were assessed using hypothetical cases in which providers were asked to evaluate their likelihood of pursuing listed treatment options.

    In total, 170 Dutch healthcare providers, including 82 urologists, 31 oncologists, and 57 oncology nurses completed the survey. Sixty-two percent of urologists, 65% of oncologists, and 51% of oncology nurses found that mCRPC patients take a passive role in decision-making and delegate treatment decisions to doctors due to advanced age (p = .45). Yet, 70% of urologists, 71% of oncologists, and 63% of oncology nurses agreed that mCRPC patients should be always involved in decision-making (p = .91). Fifty-two percent of urologists and 55% of oncologists stated that they are inadequately trained to apply SDM in clinical practice. Conversely, only 20% of oncology nurses believed that oncology nurses are inadequately trained. Fifty-four percent of all providers considered a DA suitable to support these patients and their healthcare providers in the decision-making process.

    All hypothetical cases showed variation in treatment recommendations among providers, with each of the five treatments ranging from extremely likely to extremely unlikely.

    The wide variation of treatment recommendations observed among the multidisciplinary team suggests that mCRPC patients and their healthcare providers may benefit from implementation of informed SDM. Given the perceived passive role of older patients with mCRPC in decision-making, interventions to engage them are needed. With slightly more than half of respondents finding DAs useful to facilitate the decision-making process, development and implementation of a DA would be an interesting field of research.

  6. #96
    Surgery Versus Radiation for High-risk Prostate Cancer: The Fight Continues. But Is It Time To Call a Draw and Reach Consensus?



    Management of high-risk prostate cancer (PC) is one of the most contentious issues that urologists face. Level 1 evidence shows that adding external beam radiotherapy (EBRT) to androgen deprivation therapy (ADT) improves survival outcomes in high-risk and locally advanced PC [1]. The only randomized trial examining surgery in this setting, SPCG-15 (www.spcginfo.org), will not report for another 10 yr, so urologists can either refer patients with high-risk PC for radiotherapy (RT) plus ADT or consider an unproven treatment like radical prostatectomy (RP).  

  7. #97
    Does time from diagnosis to treatment of high or very high risk prostate cancer affect outcome?



    To determine whether time from diagnosis to treatment impacted outcomes in a multi‐center cohort of high and very high risk (VHR) prostate cancer (PCa) patients undergoing radical prostatectomy (RP).

    Subjects and Methods
    1392 patients from three tertiary centers who underwent RP for either high risk or VHR disease from 2005‐2015 were identified. The cohort was divided into tertiles based on time from diagnostic biopsy to RP. Cumulative incidence of biochemical recurrence (BCR), metastasis, and prostate cancer specific mortality (PCSM) were calculated for each tertile. Kaplan‐Meier method was used to evaluate for differences in all cause mortality (ACM) among tertiles. Competing risks regression models as well as cox proportional hazards regression models were fit to assess association between time‐to‐event outcomes and patient characteristics.

    Median time from biopsy to radical prostatectomy was 68 days (IQR 50‐94). Median follow up was 31 months (IQR 12.1‐55.7). Cumulative incidence of BCR (p=0.14), metastasis (p=0.15), and PCSM (p=0.69) did not differ among time to treatment tertiles of VHR patients. Kaplan‐Meier estimates of ACM (p=0.53) also did not differ among time to treatment tertiles. BCR, metastasis, PCSM, and ACM also did not significantly differ among time to treatment tertiles in multivariable modeling.

    In this pooled meta‐dataset of patients with high or VHR prostate cancer, time from diagnosis to radical prostatectomy did not appear to significantly contribute to differences in clinical outcomes. This finding supports the safety of enrollment of such patients into neoadjuvant clinical trials.

  8. #98
    Confirmatory MRI With or Without Biopsy Impacts Decision-Making in Newly Diagnosed Favorable Risk Prostate Cancer



    To investigate how MRI and post-MRI biopsy (pMRI-Bx) impact decision-making in men considering active surveillance (AS).

    Materials and Methods:
    We reviewed men in the Michigan Urological Surgery Improvement Collaborative with newly diagnosed favorable risk prostate cancer. Following the diagnostic biopsy (dBx), men were classified into three groups: 1) no MRI, 2) MRI only, and 3) MRI/pMRI-Bx. For the purpose of counseling and shared decision-making, MRI results were deemed reassuring (RA) (PIRADS ≤3) or nonRA (PIRADS ≥4). Similarly, if the dBx was GG1, pMRI-Bx results were deemed nonRA if there was any amount of ≥GG2; if the dBx was GG2, pMRI-Bx results were deemed nonRA if >3 cores GG2, >50% GG2 in any individual core, or any volume of ≥GG3.

    Of 1461 men with FRPC, 1223 men (84%) did not have a MRI, 157 (11%) men had a MRI alone, and 81 (6%) men had a MRI/pMRI-Bx. Of the men with a MRI alone, more men with a RA MRI (74%) chose AS compared with a nonRA MRI (35%) or men without a MRI (42%). The highest rate of AS occurred in men with a RA pMRI-Bx regardless of whether the MRI was RA or nonRA (93% and 96%, respectively).

    MRI and pMRI-Bx drive decision-making in men with newly diagnosed favorable risk prostate cancer. pMRI-Bx is a stronger driver of decision-making than MRI alone as demonstrated by the high proportion (>90%) of men with a RA pMRI-Bx who chose AS regardless of MRI results.

  9. #99
    Underutilization of Androgen Deprivation Therapy with External Beam Radiotherapy in Men with High-grade Prostate Cancer
    [2019, Full Text]



    Multiple randomized trials have shown a survival benefit to long durations of androgen deprivation therapy (ADT) in patients with Gleason grade group (GG) 4–5 (ie, Gleason score 8–10) prostate cancer (PCa) undergoing definitive external beam radiotherapy (EBRT). We conducted a population-based retrospective study utilizing the complete Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database from 2008 to 2011, extracting PCa patients of non-Hispanic white (NHW) and African-American (AA) race diagnosed with GG 4–5 PCa who received EBRT with or without concomitant ADT. Of 961 patients receiving definitive EBRT, 225 (23.4%) received no ADT, 297 (30.9%) received 1–6 mo of ADT, 313 (32.6) received 7–23 mo of ADT, and 126 (13.1%) received ≥24 mo of ADT. On multinomial logistic regression after inverse probability treatment weighting to balance for differences in other covariates, AA men still had significantly lower odds of receiving 1–6 mo of ADT versus no ADT compared with NHW men (odds ratios 0.519 [95% confidence interval, 0.384–0.700]). In conclusion, long-duration ADT is underutilized, with nearly 90% of patients with GG 4–5 PCa receiving <24 mo of concomitant ADT, and AA men are less likely to receive ADT than NHW men.

    Patient summary

    In this report, we examined the utilization of concomitant androgen deprivation therapy (ADT) among men with high-grade prostate cancer undergoing definitive external beam radiotherapy. We found that long-duration ADT was underutilized overall; moreover, African-American men were less likely to receive concomitant ADT than non-Hispanic white men.

  10. #100
    Impact of patient choice and hospital competition on patient outcomes after prostate cancer surgery: A national population‐based study



    Policies that encourage patient choice and hospital competition have been introduced across several countries with the purpose of improving the quality of health care services. The objective of the current national cohort study was to analyze the correlation between choice and competition on outcomes after cancer surgery using prostate cancer as a case study.

    The analyses included all men who underwent prostate cancer surgery in the United Kingdom between 2008 and 2011 (n = 12,925). Multilevel logistic regression was used to assess the effect of a radical prostatectomy center being located in a competitive environment (based on the number of centers within a threshold distance) and being a successful competitor (based on the ability to attract patients from other hospitals) on 3 patient‐level outcomes: postoperative length of hospital stay >3 days, 30‐day emergency readmissions, and 2‐year urinary complications.

    With adjustment for patient characteristics, men who underwent surgery in centers located in a stronger competitive environment were less likely to have a 30‐day emergency readmission, irrespective of the type or volume of procedures performed at each center (odds ratio, 0.46; 95% confidence interval, 0.36‐0.60; P = .005). Men who received treatment at centers that were successful competitors were less likely to have a length of hospital stay >3 days (odds ratio, 0.49; 95% confidence interval, 0.25‐0.94; P = .02).

    The current results suggest for the first time that hospital competition improves short‐term outcomes after prostate cancer surgery. Further evaluation of the potential role of patient choice and hospital competition is required to inform health service design in contrast to the role of top‐down–driven approaches, which have focused on centralization of services.


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