Badly judged and biased political spin from the European Association for Urology

According to a media release issued by the European Association of Urology on Saturday, just prior to the opening of their annual meeting in Milan, Italy, “Surgery is superior to radiotherapy in men with localized [prostate cancer].” This headline is not even justifiable based on the content of the media release.

The media release, which announces the results of a retrospective, observational study conducted by a team of Dutch and Swedish researchers and is based on data from Sweden’s National Prostate Cancer Registry, represents a classic case of “spinning” data to justify a point of view that the actual data do not necessarily support at all. A politician would be proud of it. The urology community should be ashamed of it.

Sooriakumaran et al. reviewed data on the outcomes of 34,515 men diagnosed with prostate cancer and treated in Sweden and for whom at least 15 years of follow-up were available. In other words, these were all men diagnosed prior to 1997. They included:

  • Men with localized, low-risk disease (risk group 1)
  • Men with localized, intermediate-risk disease (risk group 2)
  • Men with localized, high-risk disease (risk group 3) and
  • Men with non-localized disease, i.e., men with clinical stages including T3-4, N+, and M+ and PSA levels >50 ng/ml (risk group 4)

Of the 34,514 men treated in this cohort, 21,533 received radical prostatectomy as their first-line therapy and 12,982 received some form of external beam radiation therapy (and maybe not even three-dimensional conformal beam radiation therapy at that).

The researchers clearly state in the media release that,

… radiotherapy patients generally had higher Gleason sums and clinical stages, were older, and had higher PSA than patients that underwent surgery (p < 0.0001 for all comparisons).

So they weren’t comparing apples to apples at all. What is more, the surgical and radiotherapeutic techniques in use in Sweden in 1997 bear little relation to the techniques being used in Sweden today, and it is less than clear that the risk groups identified above actually correspond to the D’Amico low-, intermediate-, and high-risk groups, since many of these patients were probably first identified based on clinical symptoms rather than an elevated PSA level.

The media release provides three study results that are probably accurate based on the available data:

  • Prostate cancer-specific mortality increased as a proportion of overall mortality among higher patient risk groups for both the surgery and radiotherapy cohorts.
  • Among the men with localized prostate cancer (risk groups 1-3), survival outcomes favored surgery.
  • Among the men with locally advanced/metastatic disease (risk group 4), treatment results were similar.

Frankly, “Duh!”

Given when these men were diagnosed and treated, there is absolutely nothing surprising about such results. However, for a man of 65 diagnosed with prostate cancer tomorrow morning, these are meaningless data.

And of course there is no mention whatsoever of the side effects or complications of treatment.

One of the most telling statements in the entire media release is the following (apparently a direct quote from the lead author of the study):

A very long follow up period is needed to make any comments regarding comparative oncologic outcomes between treatments. Hence, the use of active surveillance may be appropriate in men with low risk disease.

However, somehow, Dr. Sookriakumaran is also quoted as follows:

The current gold standard management of localized prostate cancer is radical therapy, either as surgery or radiation therapy. This study suggests that surgery is likely superior to radiation for the majority of men who have localized prostate cancer, especially the younger age group and those with no or few comorbidities.

Either this quotation is delusional or it has been taken completely out of its original context.

The only reasonable conclusion to be drawn from this study is actually the following:

  • Men being treated 15 years ago in Sweden, and often diagnosed based on clinical parameters, appear to have better outcomes if they were lower in risk and treated surgically. However, the men treated surgically are not clinically comparable to the men treated by radiation therapy.

2 Responses

  1. Here’s the deal Mr. Sitemaster (what ever that is): If you remove the prostate you know for a fact that all the cancer in the prostate is gone. The same is not true for using radiation or any other form of energy. So it stands to reason that surgical removal has a higher likelihood of cure. Not saying clinically significant. Just common sense. Don’t be so scientifically clever by half!

  2. Dear Dr. McHugh:

    I have never, ever denied that the available data suggest that radical surgery is more likely to eliminate prostate cancer in a man with localized disease than any other form of treatment. However, as you well understand, that is not the only critical factor. Others are whether any form of invasive treatment was actually necessary at all (for a very large proportion of men with low- and very low-risk disease) and whether the patient really has the relevant data and understands how to assess the balance of quality vs. quantity of life.

    Another paper that is being presented at the EAU this week (and that I shall comment on tomorrow morning) suggests that only 17% of radical prostatectomy patients at a large, academic Swedish medical cancer who were potent prior to their surgery were still potent 18 months post-surgery. I hope you personally can do a lot better that that, and have data to confirm it, but how many patients who were given surgery at that center do you think were given a clear message about this before they agreed to surgery.

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