A Comparison Between Low-Dose-Rate Brachytherapy With or Without Androgen Deprivation, External Beam Radiation Therapy With or Without Androgen Deprivation, and Radical Prostatectomy With or Without Adjuvant or Salvage Radiation Therapy for High-Risk Prostate Cancer.
We compare the efficacy and toxicity among the 3 major modalities available used to treat high-risk prostate cancer (HRCaP).



From 1996 to 2012, 2557 HRCaP patients were treated: 734 received external beam radiation therapy (EBRT) with or without androgen deprivation therapy (ADT), 515 received low-dose-rate prostate brachytherapy (LDR) with or without ADT, and 1308 received radical prostatectomy (RP) with or without EBRT. Biochemical relapse-free survival (bRFS), clinical relapse-free survival (cRFS), and prostate cancer-specific mortality (PCSM) were assessed. Toxicity was assessed using the Common Terminology Criteria for Adverse Events, version 4.03. The log-rank test compared bRFS and cRFS among the modalities, and Cox regression identified factors associated with bRFS and cRFS. Gray's test compared differences in late toxicity and PSCM among the modalities. Competing risk regression identified factors associated with PCSM.



The median follow-up time and age were 63.5 months and 65 years, respectively. The bRFS at 5 and 10 years, respectively, was 74% and 53% for EBRT, 74% and 52% for LDR, and 65% and 47% for RP (P=.0001). The cRFS at 5 and 10 years, respectively, was 85% and 73% for EBRT, 90% and 76% for LDR, and 89% and 75% for RP (P=.121). The PCSM at 5 and 10 years, respectively, was 5.3% and 11.2% for EBRT, 3.2% and 3.6% for LDR, and 2.8% and 6.8% for RP (P=.0004). The 10-year cumulative incidence of ≥grade 3 genitourinary toxicity was 8.1% for EBRT, 7.2% for LDR, and 16.4% for RP (P<.0001). The 10-year cumulative incidence of ≥grade 3 gastrointestinal toxicity was 4.6% for EBRT, 1.1% for LDR, and 1.0% for RP (P<.0001).



HRCaP treated with EBRT, LDR, or RP yields efficacy showing better bRFS for LDR and EBRT relative to RP, equivalence for cRFS, and a PCSM advantage of LDR and RP over EBRT. The toxicity is lowest for LDR.
Taussig Cancer Institute, Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio. Electronic address: ciezkij@ccf.org.
Jay P
JP
Ciezki
Taussig Cancer Institute, Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
Michael
M
Weller
Taussig Cancer Institute, Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
Chandana A
CA
Reddy
Taussig Cancer Institute, Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
Jeffrey
J
Kittel
Taussig Cancer Institute, Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
Harguneet
H
Singh
Taussig Cancer Institute, Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
Rahul
R
Tendulkar
Taussig Cancer Institute, Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
Kevin L
KL
Stephans
Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, Ohio.
James
J
Ulchaker
Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, Ohio.
Kenneth
K
Angermeier
Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, Ohio.
Andrew
A
Stephenson
Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, Ohio.
Steven
S
Campbell
Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, Ohio.
Georges-Pascal
GP
Haber
Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, Ohio.
Eric A
EA
Klein
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000726:Androgen Antagonists / Q000008:administration & dosage; D001918:Brachytherapy / Q000401:mortality* / Q000706:statistics & numerical data; D059248:Chemoradiotherapy / Q000401:mortality* / Q000706:statistics & numerical data; D018572:Disease-Free Survival; D005767:Gastrointestinal Diseases / Q000401:mortality* / Q000517:prevention & control; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009820:Ohio / Q000453:epidemiology; D011468:Prostatectomy / Q000401:mortality* / Q000706:statistics & numerical data; D011471:Prostatic Neoplasms / Q000401:mortality* / Q000628:therapy*; D011832:Radiation Injuries / Q000401:mortality / Q000517:prevention & control; D018714:Radiotherapy, Adjuvant / Q000401:mortality / Q000706:statistics & numerical data; D020266:Radiotherapy, Conformal / Q000401:mortality* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000401:mortality / Q000706:statistics & numerical data; D015996:Survival Rate; D016896:Treatment Outcome
D000726:Androgen Antagonists