Patient-reported outcomes after curative treatment for prostate cancer with prostatectomy, primary radiotherapy or salvage radiotherapy

Figures & data

Table 1. Patient characteristics according to type of curative treatment.

	Radical prostatectomy n = 406	Primary radiotherapy n = 265	Salvage radiotherapy n = 116
Age at start of treatment (median (IQR), years)	65.1 (60.6–69.6)	73.5 (70.3–76.7)	66.3 (61.0–71.6)
PSA ^a (median (IQR), µg/mL)	8.9 (5.6–12.2)	11.0 (5.8–16.3)	10.3 (9.6–14.9)
PSA at start of RT (median (IQR), µg/mL)		0.2 (0–0.5)	0.4 (0–0.9)
ISUP grade group^b
1	142 (35.0)	18 (6.8)	16 (13.8)
2	142 (35.0)	56 (21.1)	26 (22.4)
3	58 (14.3)	86 (32.5)	23 (19.6)
4	45 (11.1)	69 (26.0)	36 (31.0)
5	19 (4.7)	36 (13.6)	15 (12.9)
T stage^c
T1a-c	4 (1.0)	10 (3.8)	0
T2	280 (69.1)	119 (44.9)	43 (37.1)
T3a	79 (19.5)	87 (32.8)	40 (34.5)
T3b	40 (9.9)	43 (16.2)	31 (26.7)
T4	2 (0.5)	0	2 (1.7)
N stage^d
N0	388 (95.6)	261 (98.5)	112 (96.7)
N1	18 (4.4)	2 (0.8)	3 (2.6)
Prostate cancer risk group at treatment^e
Low risk	23 (5.7)	4 (1.5)	6 (5.2)
Intermediate risk	205 (50.6)	61 (23.0)	36 (31.0)
High risk	177 (43.7)	200 (75.5)	74 (63.8)
Comorbidity
Hypertension	117 (28.8)	120 (45.3)	37 (31.2)
Coronary disease	41 (10.1)	64 (24.2)	11 (9.5)
Diabetes mellitus	18 (4.4)	42 (15.8)	5 (4.3)

n: number; IQR: interquartile range; RT: radiotherapy; PSA: prostatic specific antigen; ISUP: International Society of Urological Pathology. Data are presented as n (%) unless otherwise stated.

^aPSA reported at start of primary treatment.

^bThe ISUP grade system classifies patients into five groups based on Gleason score: grade 1 Gleason score = 6; grade 2 Gleason score 3 + 4 = 7; grade 3 Gleason score 4 + 3 = 7; grade 4 Gleason score 8 and grade 5 Gleason scores 9–10 [18].

^cFor men treated with surgery (radical prostatectomy and salvage radiotherapy) pathological T-stage is reported. Data missing for one patient treated with radical prostatectomy who had no tumour material in the resected specimen, all tumour tissue probably removed at biopsy. For men treated with primary radiotherapy, radiological T stage is reported (missing data for 6 patients; no MRI scan due to ICD/pacemaker/claustrophobia (n = 4), previous transurethral resection of prostate (n = 1), not reported (n = 1)).

^dFor men treated with radical prostatectomy, pathological N stage is reported when lymph node removal was performed. For remaining patients and for men treated with radiotherapy, radiological N stage is reported. For 3 men (2 primary radiotherapy, 1 salvage) radiological N stage is missing as MRI was not performed due to ICD/pacemaker.

^eRisk group according to European Association of Urology (EAU) guidelines: High risk patients had American Joint Committee of Cancer (AJCC) clinical T stage ≥2c, or PSA level >20 ng/mL or ISUP grade 4/5. Intermediate risk patients had AJCC clinical T stage 2b, or PSA level 10–20 or ISUP grade 2/3. Low risk patients had AJCC clinical T stage ≤ 2a, PSA level < 10 ng/mL and ISUP grade 1 [19]. Based on radiological T stage when available, otherwise clinical T stage.

Figure 1. Flow chart presenting the study population. RALP = Robotic-assisted laparoscopic prostatectomy; n = number; EPIC-26 = Expanded Prostate Cancer Index Composite 26-item. ¹The database for surgical patients were administered by different personnel than the radiotherapy database and information about reasons for exclusion is missing. ²Data are presented as n (%). ³49 of the RALP patients were later included in the radiotherapy registry as they received salvage radiotherapy.

Table 2. Treatment details.

	Radical prostatectomy n = 406	Primary radiotherapy n = 265	Salvage radiotherapy n = 116
Surgery:
Type of surgery
RALP	406 (100)		96 (82.8)
Open retropubic			19 (16.4)
Laparoscopic			1 (0.9)
Lymph node removal^a	145 (35.7)		81 (69.8)
Limited	57 (14.0)		38 (32.8)
Expanded	88 (21.7)		42 (36.2)
Nerve sparing^b	197 (48.5)		58 (50.0)
Unilateral	118 (29.1)		40 (34.5)
Bilateral	79 (19.5)		18 (15.5)
Positive margins	73 (18.0)		58 (50.0)
Time from surgery to salvage radiotherapy (median (IQR), months)			20.1 (0–50.2)
Radiotherapy:
Radiotherapy regimen^c
60 Gy		79 (29.8)
77 Gy		186 (70.1)
70 Gy			116 (100)^4
Pelvic lymph node irradiation		73 (27.5)	54 (56.6)
Androgen deprivation therapy		259 (97.7)	107 (92.2)

n: number; RALP: Robotic assisted laparoscopic prostatectomy; IQR: interquartile range. Date are presented as n (%) unless otherwise stated.

^a,bMissing data on type of lymph node removal and nerve sparing for one salvage patient operated abroad.

^cFourt-en men with high risk disease were treated as intermediary risk patients with a total radiotherapy dose of 60 Gy. For 7 of these a shorter regimen was chosen due to the covid epidemic, while for the other 7 a lower radiotherapy dose was chosen due to comorbidity/high age/less aggressive disease.

^d17 patients received adjuvant radiotherapy due to affected surgical margin (n = 14) or measurable PSA (n = 3).

Figure 2. EPIC-26 mean domain summary scores across treatment groups before and 3 months after treatment. EPIC-26 = Expanded Prostate Cancer Index Composite 26-item; SD = standard deviation.

Figure 3. EPIC-26 mean domain summary score changes across treatment groups from pre-treatment to 3 months after treatment. EPIC-26 = Expanded Prostate Cancer Index Composite 26-item. Brackets indicate standard deviation. *indicate change exceeding the minimally clinically important differences. Changes in domain score was calculated for patients who completed EPIC-26 both pre-treatment and at three months after treatment

Table 3. EPIC-26 domain summary scores and problem scores.

	RALP (n = 406)			Primary radiotherapy (n = 265)			Salvage radiotherapy (n = 116)
	Pre-treatment	3 months	Change^a	Pre-treatment	3 months	Change^a	Pre-treatment	3 months	Change^a
Urinary incontinence DSS	90.2 (17.8)	48.2 (28.5)	−41.7 (30.7)*	88.8 (17.0)	86.8 (19.6)	−1.9 (17.5)	69.4 (27.2)	61.3 (31.2)	−7.3 (18.2)*
Urinary irritative DSS	80.0 (16.8)	81.0 (15.8)	1.6 (19.5)	80.1 (16.5)	73.8 (20.0)	−5.2 (19.6)*	87.9 (13.3)	81.3 (16.6)	−7.5 (14.0)*
Urinary problem	79.1 (27.7)	56.9 (31.0)	−21.8 (34.7)	72.9 (29.0)	64.6 (30.6)	−8.3 (22.3)	75.0 (28.1)	58.2 (32.3)	−15.5 (29.3)
Bowel DSS	90.4 (13.9)	89.0 (14.6)	−0.7 (14.5)	92.9 (10.6)	84.5 (17.2)	−8.2 (15.1)*	91.7 (11.9)	78.7 (21.1)	−12.5 (16.1)*
Bowel problem	89.8 (19.7)	87.3 (21.3)	−2.8 (21.7)	88.4 (19.3)	77.7 (25.6)	−10.8 (26.4)	86.9 (20.1)	70.9 (30.2)	−17.1 (25.4)
Sexual DSS	67.6 (26.9)	22.4 (23.9)	−46.1 (30.2)*	23.0 (19.0)	16.7 (16.5)	−5.9 (15.9)	29.1 (26.3)	14.7 (17.3)	−14.9 (18.9)*
Sexual problem	66.8 (32.1)	28.3 (31.9)	−39.3 (42.7)	50.5 (36.2)	46.4 (40.5)	−3.0 (32.9)	42.8 (34.6)	36.1 (35.0)	−8.7 (33.1)
Hormonal DSS	84.2 (15.9)	83.4 (16.1)	−1.0 (13.9)	74.3 (18.4)	63.9 (19.4)	−9.6 (18.2)*	85.7 (14.8)	60.8 (23.8)	−23.8 (20.9)*

EPIC-26: Expanded Prostate Cancer Index Composite 26-item; RALP: Robotic assisted laparoscopic prostatectomy; n: numbers; DSS: domain summary score.

Data are presented as mean (standard deviation).

^aChange in domain score was calculated for patients who completed EPIC-26 both pre-treatment and at three months after treatment; 209 men treated with RALP, 195 men treated with primary radiotherapy and 90 men treated with salvage radiotherapy.

*Clinically relevant (exceeding minimally clinically important differences).

Epstein JI, Egevad L, Amin MB, et al. The 2014 international society of urological pathology (ISUP) consensus conference on gleason grading of prostatic carcinoma: definition of grading patterns and proposal for a new grading system. Am J Surg Pathol. 2016;40(2):244–252. doi: 10.1097/PAS.0000000000000530.

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Surgery Versus Radiotherapy for Locally Advanced Prostate Cancer (SPCG-15). ClinicalTrials.gov Identifier: NCT02102477. 2022. Available from: https://clinicaltrials.gov/ct2/show/NCT02102477.

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Data availability statement

The data are not available due to restrictions from the data protection officer and the Regional Committee for Medical and Research Ethics.