Association of Radical Local Treatment with Mortality in Men with Very High-risk Prostate Cancer: A Semiecologic, Nationwide, Population-based Study

Pär Stattin, Fredrik Sandin, Frederik Birkebæk Thomsen, Hans Garmo, David Robinson, Ingela Franck Lissbrant, Håkan Jonsson, Ola Bratt

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    Abstract

    Background

    Current guidelines recommend androgen deprivation therapy only for men with very high-risk prostate cancer (PCa), but there is little evidence to support this stance.

    Objective

    To investigate the association between radical local treatment and mortality in men with very high-risk PCa.

    Design, setting, and participants

    Semiecologic study of men aged <80 yr within the Prostate Cancer data Base Sweden, diagnosed in 1998–2012 with very high-risk PCa (local clinical stage T4 and/or prostate-specific antigen [PSA] level 50–200 ng/ml, any N, and M0). Men with locally advanced PCa (local clinical stage T3 and PSA level <50 ng/ml, any N, and M0) were used as positive controls.

    Intervention

    Proportion of men who received prostatectomy or full-dose radiotherapy in 640 experimental units defined by county, diagnostic period, and age at diagnosis.

    Outcome measurements and statistical analysis

    PCa and all-cause mortality rate ratios (MRRs).

    Results and limitations

    Both PCa and all-cause mortality were half as high in units in the highest tertile of exposure to radical local treatment compared with units in the lowest tertile (PCa MRR: 0.51; 95% confidence interval [CI], 0.28–0.95; and all-cause MRR: 0.56; 95% CI, 0.33–0.92). The results observed for locally advanced PCa for highest versus lowest tertile of exposure were in agreement with results from randomized trials (PCa MRR: 0.75; 95% CI, 0.60–0.94; and all-cause MRR: 0.85; 95% CI, 0.72–1.00). Although the semiecologic design minimized selection bias on an individual level, the effect of high therapeutic activity could not be separated from that of high diagnostic activity.

    Conclusions

    The substantially lower mortality in units with the highest exposure to radical local treatment suggests that radical treatment decreases mortality even in men with very high-risk PCa for whom such treatment has been considered ineffective.

    Patient summary

    Men with very high-risk prostate cancer diagnosed and treated in units with the highest exposure to surgery or radiotherapy had a substantially lower mortality.

    Original languageEnglish
    JournalEuropean Urology
    Early online date5 Aug 2016
    DOIs
    Publication statusE-pub ahead of print - 5 Aug 2016

    Keywords

    • Prostate cancer
    • Very high-risk
    • Radical
    • Treatment
    • Semiecologic
    • Nationwide
    • Population-based
    • PCBaSe

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