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Thread: (F) Treatment Decisions Comparisons Trends

  1. #161
    The role of salvage lymph node dissection in nonmetastatic castration-resistant prostate cancer: A single center experience



    To evaluate oncologic outcomes of patients with nonmetastatic, castration-resistant prostate cancer treated with salvage lymph node dissection (sLND) or androgen-deprivation therapy (ADT) for lymph nodes (LN)-only recurrence.

    Retrospective analysis of 23 (51.1%) patients who underwent sLND and 22 (48.9%) men who received ADT for LN-only recurrence. Biochemical recurrence (BCR) was defined as prostate-specific antigen (PSA) >0.2 ng/ml with an increased trend and radiological recurrence (RAR) was defined as a positive imaging study after sLND or ADT. Second line systemic therapies (SST) were defined as any systemic therapy administered for progression. Predictors of BCR, RAR, and SST were assessed with Cox regression analyses.

    Mean PSA reduction was significantly higher after sLND than ADT (62.8% vs. 17.7%; P = 0.04). Clinical outcomes were not statistically different between the 2 groups. However, there was a trend toward a longer time to BCR (13.3 vs. 6 months; P = 0.2) and RAR (21.1 vs. 14.2 months, P = 0.09) in sLND patients than ADT. Median time to SST was longer in the sLND group than ADT (P = 0.04). Univariable Cox regression analyses showed that PSA doubling time and pT stage were associated with RAR and SST (all P < 0.05).

    In patients with nonmetastatic, castration-resistant prostate cancer, sLND resulted in greater PSA decrease than ADT. We noted a nonstatistically significant trend toward longer time to BCR and longer time to RAR for patients treated with sLND than ADT. Additionally, sLND may increase time to SST as compared to ADT.

  2. #162
    How to choose proper local treatment in men aged ≥75 years with cT2 localized prostate cancer?
    [2019, Full Text]



    For localized prostate cancer (PCa), radical prostatectomy (RP) and radiotherapy (RT) are two standard interventions to decrease PCa mortality. Contemporary studies contained the elderly people; analyses focusing on patients over 75 years of age were still lacking.

    In the Surveillance Epidemiology and End Results (SEER) database (2004‐2015), people over 75 years of age with cT2 stage were selected in our research. Multivariable Cox proportional hazard models were used to analyze cancer‐specific mortality (CSM) and overall mortality (OM) after adjustment. The propensity score matching was performed to assume the randomization. An instrument variate (IVA) was used to calculate the unmeasured confounders.

    Radical prostatectomy is superior to RT in OM and CSM after adjustment for covariates (HR = 0.54, 95% CI = 0.47‐0.62, P < 0.001 and HR = 0.30, 95% CI = 0.20‐0.45, P < 0.001, respectively). The cox model after matching indicated similar consequence (OM: HR = 0.53, 95% CI = 0.46‐0.62, P < 0.001; CSM: HR = 0.27, 95% CI = 0.17‐0.43, P < 0.001). In the IVA‐adjusted model, the effect of treatment changed slightly (OM: HR = 0.65, 95% CI = 0.54‐0.78, P < 0.001; CSM: HR = 0.21, 95% CI = 0.12‐0.37, P < 0.001). Subgroup analyses showed that for patients with GS = 7, those received RP obtained the highest risk decline for overall death (HR = 0.41, 95% CI = 0.32‐0.52); and for patients with younger age, those received RP obtained the highest risk decline for CSM (HR = 0.11, 95% CI = 0.01‐0.52).

    Patients over 75 years of age with cT2 stage will obtain more benefit from RP compared with RT, especially for patients with GS = 7 and younger age.

  3. #163
    CUOS 2019: High-Risk Prostate Cancer Debate: Surgery
    [2019, Full Text]

    [CUOS = Canadian Uro-Oncology Summit]


    Toronto, Ontario (UroToday.com) In this debate, Dr. Laurence Klotz presented his view and thought on why radical prostatectomy should be performed in patients with high-risk disease, as opposed to radiotherapy.
    The main issues in a high-risk localized prostate cancer disease that need to be further assessed and researched include the following:
    1. Staging
    - The role of MRI in staging high-risk prostate cancer is still controversial
    - The are many new and upcoming imaging modalities (PSAM, Na-F PET, and others) with an unknown role in the staging and diagnosis process
    - The role of molecular biomarkers needs to be deciphered
    - The unique entity of oligometastatic disease needs to be understood better, and especially how to treat it
    2. The role of neoadjuvant cytoreduction (androgen deprivation therapy [ADT] / chemotherapy / or other) need to be understood
    3. Primary treatment – surgery vs. radiotherapy - which is better? We must finally have an answer to this old question
    4. Adjuvant therapy
    - Is radiotherapy needed after surgery?
    - What is the role of adjuvant ADT and androgen receptor antagonists
    (See Full Text)

    CUOS 2019: High-Risk Prostate Cancer Debate: Radiation [2019, Full Text]


    Toronto, Ontario (UroToday.com) Dr. Gerard Morton participated in the debate of 'High-risk Prostate Cancer Debate: Radiation vs Surgery" and explained why he believes that radiotherapy should be offered to patients with high-risk prostate cancer.
    Radiation is the standard of care for the high-risk disease. There is level one evidence that radiotherapy can cure men with this type of disease. Modern treatment with brachytherapy boost has even better results than the using only external beam radiotherapy. Dr. Morton believes that performing prostatectomy increases morbidity without improving cure and should be considered only in select cases.
    There are three important randomized controlled trials in the setting of locally advanced /high-risk disease comparing androgen deprivation therapy (ADT) to ADT + radiotherapy:
    The PR-3 trial1, which included 1206 patients
    The Scandinavian Prostate Cancer Group -7 trial2, which included 875 men
    The Mottet Trial3, which included 264 patients
    All three trials demonstrated an advantage to the radiotherapy arm in local progression and metastases development. Two of the trials demonstrated a benefit in the radiotherapy arm in cancer-specific survival and overall survival.
    (See Full Text)

  4. #164
    Age and aggressiveness of prostate cancer: analysis of clinical and pathological characteristics after radical prostatectomy for men with localized prostate cancer
    [2019, Full Text]



    Introduction The aim of this study was to describe age- related prostate cancer (PCa) characteristics in men after radical prostatectomy (RP).
    Material and methods There were 2,373 men who underwent RP for clinically localized PCa between 2002 and 2017 and had complete data that were included into the study. Among them, 315 (13.3%) men aged ≤55 years (GR-1), 1,098 (46.3%) men aged between 56 to 65 years (GR-2) and 960 (40.4%) men aged older than 65 years (GR-3) were identified. All preoperative and pathological parameters were compared between all three groups and between each group separately. High-risk prostate cancer (HRPCa) cases were analyzed separately. Regression analysis was used to evaluate the impact of age on cancer aggressiveness.
    Results Clinical stage (cT), biopsy Gleason score and D'Amico risk groups were different comparing agerelated study groups (all p <0.01), respectively. Preoperatively cT1 and Gleason 6 were in the highest rate for GR-1 in comparison with GR-3: 35.9 vs. 27.1%, p = 0.003 and 65.1% vs. 56.7%, p = 0.008, respectively. Analyzing pathological parameters, only Gleason 9–10 was different between GR-1 and GR-3–3.8 vs. 7.6%, p = 0.02. There were 921 (38.8%) HRPCa cases identified. Age was a significant predictor for HRPCa (p = 0.019) in the regression analysis. The oldest men (GR-3) had up to 1.5 fold increased risk for HRPCa detection in comparison with the youngest one (p = 0.008, HR1.44. 95% CI 1.098–1.87). Conclusions Younger, ≤55-year-old men, are more likely to present with less aggressive clinical and pathological PCa features in comparison with the older ones. Increasing age has a significant influence on HRPCa detection after RP
    This recent study confirms the accepted view that aggressive PCa is correlated with age.

  5. #165
    Contemporary prostate cancer treatment choices in multidisciplinary clinics referenced to national trends



    The purpose of this study was to assess treatment choices among men with prostate cancer who presented at The University of Texas MD Anderson Cancer Center multidisciplinary (MultiD) clinic compared with nationwide trends.

    In total, 4451 men with prostate cancer who presented at the MultiD clinic from 2004 to 2016 were analyzed. To assess nationwide trends, the authors analyzed 392,710 men with prostate cancer who were diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. The primary endpoint was treatment choice as a function of pretreatment demographics.

    Univariate analyses revealed similar treatment trends in the MultiD and SEER cohorts. The use of procedural forms of definitive therapy decreased with age, including brachytherapy and prostatectomy (all P < .05). Later year of diagnosis/clinic visit was associated with decreased use of definitive treatments, whereas higher risk grouping was associated with increased use (all P < .001). Patients with low-risk disease treated at the MultiD clinic were more likely to receive nondefinitive therapy than patients in SEER, whereas the opposite trend was observed for patients with high-risk disease, with a substantial portion of high-risk patients in SEER not receiving definitive therapy. In the MultiD clinic, African American men with intermediate-risk and high-risk disease were more likely to receive definitive therapy than white men, but for SEER the opposite was true.

    Presentation at a MultiD clinic facilitates the appropriate disposition of patients with low-risk disease to nondefinitive strategies of patients with high-risk disease to definitive treatment, and it may obviate the influence of race.

  6. #166
    Survival Associated with Radical Prostatectomy vs Radiotherapy for High-Risk Prostate Cancer: A Contemporary, Nationwide Observational Analysis



    Objdctive The optimal primary treatment for clinically high-risk prostate cancer (PCa) is controversial as both radical prostatectomy (RP) and radiotherapy (RT) with androgen deprivation therapy [ADT], being offered. Our objective was to compare overall mortality-free survival of high-risk PCa patients treated with primary RP vs primary RT with neoadjuvant/adjuvant ADT within the National Cancer Data Base (NCDB). MethodsWithin NCDB, a total of 87 875 high-risk PCa patients fulfilled our inclusion criteria (53 197 in RP group and 34 678 in RT+ADT (neoadjuvant/adjuvant) group). We employed instrumental variable analysis (IVA) approach using the yearly rate of RP as the instrument. Sensitivity analyses were performed stratified according to age, comorbidity, ADT utilization and high-dose (>75.6 Gy) RT. In addition, the outcome of RP was compared to that of RT reported in three contemporary randomized controlled trails (RCTs), after selecting only those RP patients from the NCDB who fitted inclusion/exclusion criteria of these RCTs. Results On IVA, primary RP was associated with lower overall mortality compared to primary RT+ADT (hazard ratio (HR) 0.52; 95% CI, 0.47-0.57; P < 0.001). Outcomes after primary RP were found to be better than those treated with RT+neoadjuvant (HR 0.52; P < 0.001) or adjuvant ADT (HR 0.47; P < 0.001), and in those treated with high-dose RT (HR 0.54; P < 0.001). While the survival outcomes for patients treated with RT (+/-ADT) in the RCTs were not statistically different from similar patients within the NCDB, RP was associated with greater overall mortality-free survival than any arms in RCTs. Conclusions In patients with clinically high-risk PCa, primary RP is associated with an overall mortality-free survival benefit compared to primary RT+ADT, regardless of baseline characteristics.
    Last edited by DjinTonic; 12-05-2019 at 02:47 PM.


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