Radical prostatectomy confers superior survival compared to radiotherapy with androgen deprivation in high-risk prostate cancer: a propensity score-matched analysis

Background: Radical prostatectomy (RP) and radiotherapy combined with androgen deprivation therapy (XRT + ADT) represent the standard definitive treatment strategies for high-risk prostatic adenocarcinoma. Using the National Cancer Database (NCDB), we compared the overall survival (OS) outcomes of RP, XRT + ADT, and secondary therapy (ST) to better understand the current landscape of treatment patterns and patient-specific prognosticators.

Methods: Men with high-risk prostate cancer (PCa) were identified for this retrospective cohort study and had received either RP or XRT + ADT as their initial treatment course. XRT + ADT was defined as external beam radiation therapy (EBRT) to the prostate/pelvis, with ADT initiated within 90 days and having not first received RP. Clinical, demographic, and pathologic characteristics were obtained, and nearest neighbor propensity score matching without replacement using a 1:1 ratio was performed on significantly different clinicopathologic variables. Multiple logistic regression models were used to predict (I) the receipt of XRT + ADT as primary treatment and (II) the receipt of any ST. ST was defined as XRT ± ADT to the prostate/pelvis following initial RP. Survival analysis was performed using the Cox proportional hazards model and the Kaplan-Meier method.

Results: A total of 86,282 men who underwent treatment between 2004 and 2019 met the inclusion and exclusion criteria; 64% underwent RP first, and 36% underwent XRT + ADT first. Following propensity score matching, a total of 61,468 patients were analyzed. After propensity matching, XRT + ADT patients were still more likely to be older and have Medicare insurance (all P<0.05). Median follow-up for all patients was 5.1 years. Within the RP group, 4,857 (15.8%) received ST (XRT ± ADT) with a median time of 3.4 months from the date of surgery. Survival analysis showed that the RP group fared better (93.5% OS at 5 years versus 85.9%). This also held true for RP + ST patients (90.4% 5-year OS). Similarly, when controlling for patient demographics (including age) and disease characteristics (including clinical stage), the resulting hazard ratio for the XRT + ADT group compared to RP was 1.88 [95% confidence interval (CI): 1.80–1.97, P<0.001], indicating worse survival outcomes for these patients.

Conclusions: Our study suggests that while each modality has its risks and benefits, RP with or without the addition of ST may still provide better survival outcomes over XRT + ADT alone when utilized as the primary definitive treatment in appropriately selected high-risk patients.