title: Radical Prostatectomy or External Beam Radiation Therapy vs No Local Therapy for Survival Benefit in Metastatic Prostate Cancer: A SEER-Medicare Analysis.
abstract: OBJECTIVE
  We assessed survival after radical prostatectomy, intensity modulated radiation therapy or conformal radiation therapy vs no local therapy for metastatic prostate cancer adjusting for patient comorbidity, androgen deprivation therapy and other factors.
  
  
  METHODS
  We identified men 66 years old or older with metastatic prostate cancer treated with radical prostatectomy, intensity modulated radiation therapy, conformal radiation therapy or no local therapy in the SEER-Medicare linked database from 2004 to 2009. Multivariable Cox proportional hazards models before and after inverse propensity score weighting were used to assess all cause and prostate cancer specific mortality. Competing risk regression analysis was done to assess prostate cancer specific mortality.
  
  
  RESULTS
  Of 4,069 men with metastatic prostate cancer radical prostatectomy in 47, intensity modulated radiation therapy in 88 and conformal radiation therapy in 107 were selected as local therapy vs no local therapy in 3,827. Radical prostatectomy was associated with a 52% decrease (HR 0.48, 95% CI 0.27-0.85) in the risk of prostate cancer specific mortality after adjusting for sociodemographics, primary tumor characteristics, comorbidity, androgen deprivation therapy and bone radiation within 6 months of diagnosis. Intensity modulated radiation therapy was associated with a 62% decrease (HR 0.38, 95% CI 0.24-0.61) in the risk of prostate specific cancer specific mortality. Conformal radiation therapy was not associated with improved survival compared to no local therapy. Propensity score weighting yielded comparable results. Competing risk analysis revealed a 42% and 57% decrease (SHR 0.58, 95% CI 0.35-0.95 and SHR 0.43, 95% CI 0.27-0.68, respectively) in the risk of prostate cancer specific mortality for radical prostatectomy and intensity modulated radiation therapy.
  
  
  CONCLUSIONS
  Local therapy with radical prostatectomy and intensity modulated radiation therapy but not with conformal radiation therapy was associated with a survival benefit in men with metastatic prostate cancer. This finding warrants prospective evaluation in clinical trials.
authors.affiliation: University of Southern California Institute of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California; Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California. Electronic address: raj.satkunasivam@gmail.com.
authors.forename: Raj
authors.initials: R
authors.lastname: Satkunasivam
authors.affiliation: Department of Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Andre E
authors.initials: AE
authors.lastname: Kim
authors.affiliation: University of Southern California Institute of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California; Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Mihir
authors.initials: M
authors.lastname: Desai
authors.affiliation: University of Southern California Institute of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California; Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Mike M
authors.initials: MM
authors.lastname: Nguyen
authors.affiliation: Department of Medical Oncology, Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California; Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: David I
authors.initials: DI
authors.lastname: Quinn
authors.affiliation: Department of Radiation Oncology, Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California; Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Leslie
authors.initials: L
authors.lastname: Ballas
authors.affiliation: Department of Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Juan Pablo
authors.initials: JP
authors.lastname: Lewinger
authors.affiliation: Department of Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Mariana C
authors.initials: MC
authors.lastname: Stern
authors.affiliation: Department of Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Ann S
authors.initials: AS
authors.lastname: Hamilton
authors.affiliation: University of Southern California Institute of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California; Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Monish
authors.initials: M
authors.lastname: Aron
authors.affiliation: University of Southern California Institute of Urology, Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California; Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, California.
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000368:Aged; D001918:Brachytherapy; D006801:Humans; D008297:Male; D006278:Medicare; D008875:Middle Aged; D057216:Propensity Score; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000175:diagnosis / Q000453:epidemiology / Q000401:mortality / Q000556:secondary / Q000628:therapy*; D020266:Radiotherapy, Conformal; D018570:Risk Assessment; D012307:Risk Factors; D018426:SEER Program; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology
keywords: SEER program; intensity-modulated; mortality; prostatectomy; prostatic neoplasms; radiotherapy