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,JAMA

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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
JAMA ( IF 63.1 ) Pub Date : 2018-03-06 , DOI: 10.1001/jama.2018.0587
Amar U. Kishan ₁ , Ryan R. Cook ₂ , Jay P. Ciezki ₃ , Ashley E. Ross ₄ , Mark M. Pomerantz ₅ , Paul L. Nguyen ₆ , Talha Shaikh ₇ , Phuoc T. Tran ₈ , Kiri A. Sandler ₁ , Richard G. Stock ₉ , Gregory S. Merrick ₁₀ , D. Jeffrey Demanes ₁ , Daniel E. Spratt ₁₁ , Eyad I. Abu-Isa ₁₁ , Trude B. Wedde ₁₂ , Wolfgang Lilleby ₁₂ , Daniel J. Krauss ₁₃ , Grace K. Shaw ₅ , Ridwan Alam ₄ , Chandana A. Reddy ₃ , Andrew J. Stephenson ₁₄ , Eric A. Klein ₁₄ , Daniel Y. Song ₈ , Jeffrey J. Tosoian ₄ , John V. Hegde ₁ , Sun Mi Yoo ₁ , Ryan Fiano ₁₀ , Anthony V. D’Amico ₆ , Nicholas G. Nickols _{1,

15} , William J. Aronson ₁₆ , Ahmad Sadeghi ₁₅ , Stephen Greco ₈ , Curtiland Deville ₈ , Todd McNutt ₈ , Theodore L. DeWeese ₈ , Robert E. Reiter ₁₆ , Johnathan W. Said ₁₇ , Michael L. Steinberg ₁ , Eric M. Horwitz ₇ , Patrick A. Kupelian _{1,

18} , Christopher R. King ₁

Affiliation

Department of Radiation Oncology, University of California, Los Angeles
Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
Department of Radiation Oncology, The Icahn School of Medicine at Mount Sinai, New York, New York
Schiffler Cancer Center, Wheeling Hospital, Wheeling Jesuit University, Wheeling, West Virginia
Department of Radiation Oncology, University of Michigan, Ann Arbor
Department of Oncology, Oslo University Hospital, the Norwegian Radium Hospital, Oslo, Norway
Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
Department of Urology, University of California, Los Angeles
Department of Pathology, University of California, Los Angeles
Varian Medical Systems, Palo Alto, California

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.

中文翻译：

Gleason 评分 9-10 前列腺癌患者的根治性前列腺切除术、外束放疗或外束放疗联合近距离放射治疗和疾病进展和死亡率

重要性 Gleason 评分 9-10 的前列腺癌的最佳治疗方法尚不清楚。目的比较 Gleason 评分 9-10 分的前列腺癌患者根治性治疗后的临床结局。设计、设置和参与者在 12 个三级中心（美国 11 个，挪威 1 个）进行的回顾性队列研究，在 2000 年至 2013 年间治疗了 1809 名患者。暴露根治性前列腺切除术 (RP)、外照射放疗 (EBRT) 和雄激素剥夺治疗，或 EBRT 加近距离放疗加强 (EBRT+BT) 和雄激素剥夺疗法。主要结果和措施主要结果是前列腺癌特异性死亡率；无远处转移生存期和总生存期是次要结果。结果在 1809 名男性中，639 人接受了 RP，734 人接受了 EBRT，436 人接受了 EBRT+BT。中位年龄分别为 61、67.7 和 67.5 岁；中位随访时间为 4。分别为 2、5.1 和 6.3 年。到 10 年时，91 名 RP、186 名 EBRT 和 90 名 EBRT+BT 患者死亡。调整后的 5 年前列腺癌特异性死亡率为 RP，12%（95% CI，8%-17%）；EBRT，13%（95% CI，8%-19%）；和 EBRT+BT，3%（95% CI，1%-5%）。EBRT+BT 与前列腺癌特异性死亡率显着低于 RP 或 EBRT 相关（原因特异性 HR 为 0.38 [95% CI，0.21-0.68] 和 0.41 [95% CI，0.24-0.71]）。调整后的 5 年远处转移发生率为 RP，24%（95% CI，19%-30%）；EBRT，24%（95% CI，20%-28%）；和 EBRT+BT，8%（95% CI，5%-11%）。EBRT+BT 与远处转移率显着降低相关（RP 的倾向评分调整原因特异性 HR 为 0.27 [95% CI，0.17-0.43]，EBRT 为 0.30 [95% CI，0.19-0.47]） . 调整后的 7.5 年全因死亡率为 RP，17%（95% CI，11%-23%）；EBRT，18%（95% CI，14%-24%）；和 EBRT+BT，10%（95% CI，7%-13%）。在随访的前 7.5 年中，EBRT+BT 与显着降低的全因死亡率相关（RP 的特定原因 HR 为 0.66 [95% CI，0.46-0.96] 和 0.61 [95% CI，0.45-0.84] ] 用于 EBRT）。在前 7.5 年之后，相应的 HR 分别为 1.16（95% CI，0.70-1.92）和 0.87（95% CI，0.57-1.32）。在接受 EBRT 或 RP 治疗的男性之间没有发现前列腺癌特异性死亡率、远处转移或全因死亡率（⩽7.5 和 >7.5 年）的显着差异（原因特异性 HR 为 0.92 [95% CI，0.67-1.26] ]、0.90 [95% CI，0.70-1.14]、1.07 [95% CI，0.80-1.44] 和 1.34 [95% CI，0.85-2.11]）。结论和相关性在 Gleason 评分为 9-10 的前列腺癌患者中，

更新日期：2018-03-06

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