Triple treatment of high-risk prostate cancer. A matched cohort study with up to 19 years follow-up comparing survival outcomes after triple treatment and treatment with hormones and radiotherapy

Abstract

Purpose: To evaluate the efficacy of a triple treatment strategy, including surgery, on high risk prostate cancer comparing long-term survival outcome with a cohort receiving standard radiotherapy with endocrine therapy.

Materials and methods: This study compared two cohorts in survival outcomes, matched on the year of diagnosis and age. In both groups there was a curative intention to treat localized high-risk prostate cancer (one or more of Gleason score 8–10, PSA 20–50 or stage T3), diagnosed between 1995–2010, follow-up at the end of 2014. Triple treatment group: 153 patients treated primarily with radical prostatectomy with neoadjuvant endocrine treatment, and a majority with adjuvant radiotherapy. Standard radiotherapy group: 702 patients with a treatment of either external radiotherapy or high dose brachytherapy combined with external beam therapy, both modalities in combination with neoadjuvant endocrine therapy.

Results: The prostate-cancer-specific mortality was 10% for the triple treatment group and 15% for the standard radiotherapy group during the period, HR = 2.01 (1.17–3.43), p = 0.011. The corresponding overall mortality was 26% vs 29%, HR = 1.54 (1.09–2.17), p = 0.015. High Gleason score was the dominating risk factor for early death due to the disease. Clinical T-stage was not an independent risk factor for death in this population.

Conclusion: Adding surgery in a multimodal treatment model in high-risk prostate cancer showed significantly better survival outcome compared with the current standard of radiotherapy. Surgery in this group is, therefore, compelling and that also includes a clinical T3-stage of the disease. The study is limited by possible selection bias for the two treatment models.

Keywords:

• Prostate cancer
• radical prostatectomy
• radiotherapy
• multimodal treatment
• high-risk prostate cancer
• hormonal therapy

Acknowledgements

This project was made possible by the continuous work of the National Prostate Cancer Register of Sweden (NPCR) steering group: Pär Stattin (chairman), Anders Widmark, Camilla Thellenberg Karlsson, Ove Andrén, Ann-Sofi Fransson, Magnus Törnblom, Stefan Carlsson, Marie Hjälm-Eriksson, David Robinson, Mats Andén, Jonas Hugosson, Ingela Franck Lissbrant, Maria Nyberg, Ola Bratt, René Blom, Lars Egevad, Calle Waller, Olof Akre, Per Fransson, Eva Johansson, Fredrik Sandin and Karin Hellström; and a special acknowledgement for our institutional nurse Evalott Davidsson for caring for our database.

Disclosure statement

There are no relationships or specific financial interests relevant to this manuscript to disclose.