Active monitoring, prostatectomy, and radiotherapy as treatment options for localized prostate cancer result in similar prostate-cancer-mortality

1. Localized prostate cancer mortality remains similar between groups receiving prostatectomy, radiotherapy, or active monitoring.

2. About 25% of men receiving active monitoring alone had local progression of their disease, as compared with roughly 10% of the prostatectomy or radiotherapy groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Prostate cancer affects thousands of men each year, but there is an ongoing controversy surrounding the best management of the disease. This study compared the 15-year effectiveness of three treatment options (active monitoring, prostatectomy, or radiotherapy) for localized prostate cancer that had been identified with prostate-specific antigen (PSA) levels. The primary outcome of this study was death from prostate cancer at 15 years of follow-up. Secondary outcomes included mortality, metastases, disease progression, and long-term androgen-deprivation therapy as noted after 15 years. This study found that of the 45 patients who had died secondary to prostate cancer, 2.2% were from the prostatectomy group, 2.9% were from the radiotherapy group, and 3.1% were from the active-monitoring group, with no difference noted between the groups. 356 patients died throughout the study from “any cause”, and there was a roughly equal number of patients from each group contributing to the overall sum. There were 104 patients who were found to have metastases during the study period (4.7% from the prostatectomy group, 5.0% from the radiotherapy group, and 9.4% from the active-monitoring group). There were 151 men who were treated with long-term androgen deprivation therapy, a majority of which belonged to the active-monitoring group (12.7%). 7.2% of patients from the prostatectomy group, and 7.7% of patients from the radiotherapy group received this treatment. Local progression of the disease was noted in 259 men, with 25.9% of the active-monitoring group, 10.5% of the prostatectomy group, and 11.0% of the radiotherapy group. Limitations to this study include the development of improved diagnostic modalities and treatments since the beginning of the study and as such, the results of this study should be cautiously considered for informing clinical decisions. Overall, the results from this study suggest that while the use of aggressive treatments for localized prostate cancer reduced disease progression, it did not affect mortality due to prostate cancer, and a greater follow-up period may be helpful to identify differences in effectiveness between treatment options.

Click to read the study in the NEJM

Relevant Reading: Patient-reported outcomes 12 years after treatment for localized prostate cancer

In-Depth [prospective cohort]: This three-armed, prospective clinical trial based in the United Kingdom enrolled 1,643 men between the ages of 50-69 years old who had recently received a diagnosis of prostate cancer. In the group receiving active monitoring (reference group), there were 545 men; there were 553 men receiving prostatectomy, and 545 men receiving radiotherapy. Of 45 patients who died from prostate cancer, 12 were from the prostatectomy group, 16 were from the radiotherapy group, and 17 were from the active-monitoring group (reference group), with no difference noted between the groups (hazard ratio (HR) for prostatectomy group was 0.66 (95% confidence interval (CI) 0.31-1.39) and 0.88 (95% CI, 0.44-1.74) for the radiotherapy group). Any-cause mortality resulted in the death of 356 patients; 124 from the active-monitoring group, 117 from the prostatectomy group (HR 0.89, 95% CI 0.69-1.15), and 115 in the radiotherapy group (HR 0.88, CI 0.68-1.13). Metastases were found in 104 patients during the study period; 26 from the prostatectomy group (HR 0.47, 95% CI 0.29-0.76), 27 from the radiotherapy group (HR 0.48, 95% CI, 0.30-0.77), and 51 from the active-monitoring group (reference group). 151 men received long-term androgen-deprivation therapy 69 of whom belonged to the active-monitoring group (reference group), while 40 patients from the prostatectomy group required this treatment (HR 0.54, 95% CI, 0.37-0.80) and 42 patients from the radiotherapy group needed it (HR 0.54, 95% CI, 0.36-0.79). In 259 men, local progression of the disease was identified. 141 patients from the active-monitoring group experienced this, whereas only 58 from the prostatectomy group did (HR 0.36, 95% CI, 0.27-0.49) and 60 from the radiotherapy group (HR 0.35, 0.26-0.48).

Image: PD

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