Surgery vs. radiotherapy as first-line treatment: an Italian perspective

An Italian study has reported data from a retrospective analysis of outcomes after radical surgery and external beam radiation therapy (EBRT) + androgen deprivation therapy (ADT) in first-line treatment of two, pre-treatment-defined, concurrently treated, high-risk patient populations, all treated at a single institution between January 2003 and December 2007.

Arcangeli et al. report that their analysis included 162 patients with high-risk prostate cancer who underwent EBRT +ADT and 122 patients with the same high-risk disease characteristics who underwent radical prostatectomy (RP). The primary endpoint was freedom from biochemical failure at 3 years of follow-up. However, patients with adverse pathologic factors post-surgery also underwent adjuvant EBRT with or without androgen deprivation therapy.

The two groups of high-risk patients were supposedly homogeneous in terms of their clinical T stage, biopsy Gleason score, and initial PSA level. The median follow-up was 38.6 and 33.8 months in the EBRT and RP groups, respectively.

The results of this study reported by the authors are:

  • The 3-year rate of freedom from biochemical failure was 86.8 percent for patients treated with EBRT and 69.8 percent for patients treated with RP.
  • The initial PSA level and the treatment type (EBRT vs. RP) were significant indicators of outcome.

The authors report that this retrospective intention-to-treat analysis showed a significantly better outcome after EBRT than after RP in patients with high-risk prostate cancer, but bthey also state that a well-conducted randomized comparison would be the best procedure to confirm these results.

The “New” Prostate Cancer InfoLink does not question these results but we have no specific information (based on the abstract) to determine whether these patients were actually appropriate for surgical care in the first place. If these patients included a significant percentage of patients with Gleason 8-10 and a PSA > 10 ng/ml, it would be open to some question whether surgery was ever an appropriate choice of treatment.

It is also somewhat puzzling that — since some patients treated surgically went on to have radiation because of specific pathologic risk factors — one did not see greater equivalence between the two groups of patients. This would seem to imply that the patients who received surgery had disease that was less likely to respond to any type of first- or second-line therapy.

The problem with all such retrospective studies that attempt to compare one form of therapy to another is that they are inherently flawed by unknown influences. We need data from studies that are conducted prospectively, not retrospectively, to get anything approaching a good answer to whether radiation is better than surgery (or vice versa) in the treatment of carefully defined sets of prostate cancer patients.

2 Responses

  1. These data are seriously flawed. The addition of ADT on one side and not the other is a definite skewing of information. ADT alone can control with similar results of the EBRT side of the study. EBRT v. RP or EBRT + ADT v. RP + ADT would be usable data comparisons.

  2. Dear Tony:

    Actually, I am not sure that you are completely correct about this. As I indicated above, it all depends on the precise clinical stages of the patients that were enrolled in the study.

    You are correct in suggesting that a different but appropriate comparison would have been surgery followed by adjuvant ADT to EBRT + adjuvant ADT, but we have long known that in high risk patients one does definitely need to add ADT to EBRT to get the best outcomes.

    Unfortunately I do not have easy access to the full content of this particular journal to see if the full article provides details of the clinical staging of the patients treated.

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