title: Primary radiotherapy versus radical prostatectomy for high-risk prostate cancer: a decision analysis.
abstract: BACKGROUND
  Two evidence-based therapies exist for the treatment of high-risk prostate cancer (PCA): external-beam radiotherapy (RT) with hormone therapy (H) (RT + H) and radical prostatectomy (S) with adjuvant radiotherapy (S + RT). Each of these strategies is associated with different rates of local control, distant metastasis (DM), and toxicity. By using decision analysis, the authors of this report compared the quality-adjusted life expectancy (QALE) between men with high-risk PCA who received RT + H versus S + RT versus a hypothetical trimodality therapy (S + RT + H).
  
  
  METHODS
  The authors developed a Markov model to describe lifetime health states after treatment for high-risk PCA. Probabilities and utilities were extrapolated from the literature. Toxicities after radiotherapy were based on intensity-modulated radiotherapy series, and patients were exposed to risks of diabetes, cardiovascular disease, and fracture for 5 years after completing H. Deterministic and probabilistic sensitivity analyses were performed to model uncertainty in outcome rates, toxicities, and utilities.
  
  
  RESULTS
  RT + H resulted in a higher QALE compared with S + RT over a wide range of assumptions, nearly always resulting in an increase of >1 quality-adjusted life year with outcomes highly sensitive to the risk of increased all-cause mortality from H. S + RT + H typically was superior to RT + H, albeit by small margins (<0.5 quality-adjusted life year), with results sensitive to assumptions about toxicity and radiotherapy efficacy.
  
  
  CONCLUSIONS
  For men with high-risk PCA, RT + H was superior to S + RT, and the result was sensitive to the risk of all-cause mortality from H. Moreover, trimodality therapy may offer local and distant control benefits that lead to optimal outcomes in a meaningful population of men.
authors: Harvard Medical School, Boston, Massachusetts, USA.
authors: Ravi
authors: R
authors: Parikh
authors: David J
authors: DJ
authors: Sher
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000726:Androgen Antagonists / Q000627:therapeutic use; D003661:Decision Support Techniques; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D017430:Prostate-Specific Antigen; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000532:radiotherapy* / Q000601:surgery*; D019057:Quality-Adjusted Life Years; D018714:Radiotherapy, Adjuvant; D012306:Risk; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000726:Androgen Antagonists; D017430:Prostate-Specific Antigen