Survival With Surgery vs Radiotherapy in Gleason Score 9–10 Prostate Cancer


Key Points

  • Survival outcomes were better with MaxRT vs radical prostatectomy alone.
  • No significant differences in survival outcomes were observed for MaxRT vs radical prostatectomy plus adjuvant RT or vs radical prostatectomy, adjuvant RT, and ADT.

In a cohort study reported in JAMA Oncology, Tilki et al found that patients with Gleason score 9–10 prostate cancer treated with multimodality therapy known as MaxRP (radical prostatectomy [RP] plus adjuvant external-beam radiotherapy [EBRT] with or without androgen-deprivation therapy [ADT]) had similar survival outcomes compared with those receiving another combination regimen called MaxRT (EBRT, brachytherapy, and ADT).

Study Details

The study involved 639 men with clinical T1–4, N0, M0 biopsy Gleason score 9–10 prostate cancer treated between February 1992 and April 2013, including 80 men consecutively treated with MaxRT at the Chicago Prostate Cancer Center and 559 men consecutively treated with RP and pelvic lymph node dissection at the German Martini-Klinik Prostate Cancer Center. Of these 559 men, 372 (66.5%) received RP alone, 88 (15.7%) received adjuvant EBRT, 49 (8.8%) received ADT, and 50 (8.9%) received both (MaxRP treatment).

The primary outcome measures were treatment propensity score–adjusted risks of prostate cancer–specific and all-cause mortality and the likelihood of equivalence of these risks between treatments in analysis using a plausibility index.

Mortality Risks

Median follow-up was 5.51 years among the 80 men treated with MaxRT and 4.78 years among the 559 men treated with RP. On multivariate analysis, risks of prostate cancer–specific mortality (hazard ratio [HR] = 2.80, P = .01) and all-cause mortality (HR = 1.65, P = .08) were higher in men undergoing RP alone compared with MaxRT. No significant differences in risks were observed vs MaxRT for RP plus adjuvant RT (HR = 0.52, P = .34 for cancer-specific mortality; HR = 0.70, P = .39 for all-cause mortality) or for RP plus adjuvant RT and ADT (MaxRP; HR = 1.33, P = .58 for cancer-specific mortality; HR = 0.80, P = .60 for all-cause mortality. RP plus adjuvant ADT alone was associated with poorer outcomes vs MaxRT (HR = 3.15, P = .01 for cancer-specific mortality; HR = 2.33, P = .01 for all-cause mortality).

For MaxRP vs MaxRT, plausibility indexes for equivalence were 76.75% for risk of prostate cancer–specific mortality and 77.97% for risk of all-cause mortality. Plausibility indexes for all other treatment comparisons were < 63%.

The investigators concluded, “Results of this study suggest that it is plausible that treatment with MaxRP or MaxRT for men with biopsy Gleason score 9–10 prostate cancer can lead to equivalent risk of [prostate cancer–specific mortality] and [all-cause mortality].”

Anthony V. D’Amico, MD, PhD, of the Department of Radiation Oncology, Dana-Farber Cancer Institute, is the corresponding author for the JAMA Oncology article.

Disclosure: See the study authors’ full disclosures at

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