Efficacy of Local Treatment in Prostate Cancer Patients with Clinically Pelvic Lymph Node-positive Disease at Initial Diagnosis

TY - JOUR

T1 - Efficacy of Local Treatment in Prostate Cancer Patients with Clinically Pelvic Lymph Node-positive Disease at Initial Diagnosis

AU - Seisen, Thomas

AU - Vetterlein, Malte W

AU - Karabon, Patrick

AU - Jindal, Tarun

AU - Sood, Akshay

AU - Nocera, Luigi

AU - Nguyen, Paul L

AU - Choueiri, Toni K

AU - Trinh, Quoc-Dien

AU - Menon, Mani

AU - Abdollah, Firas

N1 - Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

PY - 2018/3/1

Y1 - 2018/3/1

N2 - BACKGROUND: There is limited evidence supporting the use of local treatment (LT) for prostate cancer (PCa) patients with clinically pelvic lymph node-positive (cN1) disease.OBJECTIVE: To examine the efficacy of any form of LT±androgen deprivation therapy (ADT) in treating these individuals.DESIGN, SETTING, AND PARTICIPANTS: Using the National Cancer Database (2003-2011), we retrospectively identified 2967 individuals who received LT±ADT versus ADT alone for cN1 PCa. Only radical prostatectomy (RP) and radiation therapy (RT) were considered as definitive LT.INTERVENTION: LT±ADT versus ADT alone.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Instrumental variable analyses (IVA) were performed using a two-stage residual inclusion approach to compare overall mortality (OM)-free survival between patients who received LT±ADT versus ADT alone. The same methodology was used to further compare OM-free survival between patients who received RP±ADT versus RT±ADT.RESULTS AND LIMITATIONS: Overall, 1987 (67%) and 980 (33%) patients received LT±ADT and ADT alone, respectively. In the LT±ADT group, 751 (37.8%) and 1236 (62.2%) patients received RP±ADT and RT±ADT, respectively. In IVA, LT±ADT was associated with a significant OM-free survival benefit (hazard ratio=0.31, 95% confidence interval [CI]=0.13-0.74, p=0.007), when compared with ADT alone. At 5 yr, OM-free survival was 78.8% (95% CI: 74.1-83.9%) versus 49.2% (95% CI: 33.9-71.4%) in the LT±ADT versus ADT alone groups. When comparing RP±ADT versus RT±ADT, IVA showed no significant difference in OM-free survival between the two treatment modalities (hazard ratio=0.54, 95% CI=0.19-1.52, p=0.2). Despite the use of an IVA, our study may be limited by residual unmeasured confounding.CONCLUSIONS: Our findings show that PCa patients with clinically pelvic lymph node-positive disease may benefit from any form of LT±ADT over ADT alone. While not necessarily curative by itself, the use of RP or RT could be the first step in a multi-modality approach aiming at providing the best cancer control outcomes for these individuals.PATIENTS SUMMARY: We examined the role of local treatment for clinically pelvic lymph node-positive prostate cancer. We found that the delivery of radical prostatectomy or radiation therapy may be associated with an overall mortality-free survival benefit compared with androgen deprivation therapy alone.

AB - BACKGROUND: There is limited evidence supporting the use of local treatment (LT) for prostate cancer (PCa) patients with clinically pelvic lymph node-positive (cN1) disease.OBJECTIVE: To examine the efficacy of any form of LT±androgen deprivation therapy (ADT) in treating these individuals.DESIGN, SETTING, AND PARTICIPANTS: Using the National Cancer Database (2003-2011), we retrospectively identified 2967 individuals who received LT±ADT versus ADT alone for cN1 PCa. Only radical prostatectomy (RP) and radiation therapy (RT) were considered as definitive LT.INTERVENTION: LT±ADT versus ADT alone.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Instrumental variable analyses (IVA) were performed using a two-stage residual inclusion approach to compare overall mortality (OM)-free survival between patients who received LT±ADT versus ADT alone. The same methodology was used to further compare OM-free survival between patients who received RP±ADT versus RT±ADT.RESULTS AND LIMITATIONS: Overall, 1987 (67%) and 980 (33%) patients received LT±ADT and ADT alone, respectively. In the LT±ADT group, 751 (37.8%) and 1236 (62.2%) patients received RP±ADT and RT±ADT, respectively. In IVA, LT±ADT was associated with a significant OM-free survival benefit (hazard ratio=0.31, 95% confidence interval [CI]=0.13-0.74, p=0.007), when compared with ADT alone. At 5 yr, OM-free survival was 78.8% (95% CI: 74.1-83.9%) versus 49.2% (95% CI: 33.9-71.4%) in the LT±ADT versus ADT alone groups. When comparing RP±ADT versus RT±ADT, IVA showed no significant difference in OM-free survival between the two treatment modalities (hazard ratio=0.54, 95% CI=0.19-1.52, p=0.2). Despite the use of an IVA, our study may be limited by residual unmeasured confounding.CONCLUSIONS: Our findings show that PCa patients with clinically pelvic lymph node-positive disease may benefit from any form of LT±ADT over ADT alone. While not necessarily curative by itself, the use of RP or RT could be the first step in a multi-modality approach aiming at providing the best cancer control outcomes for these individuals.PATIENTS SUMMARY: We examined the role of local treatment for clinically pelvic lymph node-positive prostate cancer. We found that the delivery of radical prostatectomy or radiation therapy may be associated with an overall mortality-free survival benefit compared with androgen deprivation therapy alone.

KW - Journal Article

U2 - 10.1016/j.eururo.2017.08.011

DO - 10.1016/j.eururo.2017.08.011

M3 - SCORING: Journal article

C2 - 28890245

VL - 73

SP - 452

EP - 461

JO - EUR UROL

JF - EUR UROL

SN - 0302-2838

IS - 3

ER -