Monday, October 27, 2014

Journal Spotlight: Surgery vs. Radiation for Prostate Cancer

A number of US-based, observational studies demonstrate that surgery (radical prostatectomy) is superior to radiation therapy for younger patients and those with high-risk prostate cancer. However, most US databases use "representative" data sets, meaning they capture and follow small populations of patients that are believed to be similar to the entire US population. Each data set has its own strengths and weaknesses – and none is perfect. A recent publication by Sookrakumaran and colleagues examined the National Prostate Cancer Registry (NPCR) of Sweden – a comprehensive Swedish database that captures 98% of prostate cancer patients since 1998.

Sooriakumaran P, Nyberg T, Akre O, Haendler L, Heus I, Olsson M, Carlsson S, Roobol MJ, Steineck G, Wiklund P. Comparative effectiveness of radical prostatectomy and radiotherapy in prostate cancer: observational study of mortality outcomes. BMJ. 2014 Feb 26;348:g1502. doi: 10.1136/bmj.g1502.

This study examined over 34,000 men treated with surgery or radiation therapy for prostate cancer followed for up to 15 years. With regard to prostate cancer and total mortality after treatment, the authors found:

  • In the 21,000 men undergoing radical prostatectomy:
    • 339 prostate cancer deaths
    • 1,064 deaths from other causes
  • In the 13,000 men undergoing radiation therapy:
    • 697 prostate cancer deaths
    • 1,127 deaths from other causes
The authors used a number of complex statistical methods and demonstrated that surgery was associated with lower mortality for most patients, specifically those at the greatest risk from death from prostate cancer (young men with intermediate- or high-risk prostate cancer). Men with low-risk disease, especially older men, who have a low-risk of death from prostate cancer had no difference in survival after either treatment. The authors went to great statistical efforts to control for variables that could alter the outcomes of the analysis. Specifically, radiation therapy was given with lower doses early in the experience of the database – a sensitivity analysis demonstrated that radiation dose should not affect outcomes.

From Sooriakumaran etal. 

A number of prospective, randomized studies are underway to examine the question of surgery vs. radiation therapy for prostate cancer. However, due to the slow-progression rate of prostate cancer, results are at least 10 years away. These include the ProtecT Study in the United Kingdom and the SPCG-15 (Surgery versus Radiotherapy for Locally Advanced Prostate Cancer) Study.


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