Metastasis, Mortality, and Quality of Life for Men with NCCN High and Very High Risk Localized Prostate Cancer following Surgical and/or Combined Modality Radiation Therapies

The optimal therapy for localized high-risk prostate cancer (PCa) continues to be debated. We compared both oncologic outcomes and quality of life for men undergoing various combinations of surgery and radiotherapy (RT). Men with very and/or high-risk PCa are likely to require multimodal therapy, and those receiving external-beam RT with androgen deprivation therapy may have inferior outcomes to those also receiving brachytherapy, or surgical subjects who are appropriately managed with postoperative adjuvant or salvage RT when indicated. The overall differences in long-term quality of life are similar for men choosing surgical versus RT pathways. Purpose: To compare metastasis-free survival, overall survival, and patient-reported quality of life (QOL) of men with National Comprehensive Cancer Network high or very high risk prostate cancer after definitive surgery and/or multimodal radiotherapy (RT). Patients and Methods: We studied a retrospective cohort study of 586 patients treated between the years 2000 and 2017 receiving radical prostatectomy with or without postoperative RT, external-beam RT (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy (Brachy) boost + ADT. Patient-reported QOL for urinary, bowel, sexual, and overall physical and mental functioning was assessed using the American Urological Association symptom scale, the Sexual Health Inventory in Men, the Rectal-Function Assessment Scale, the Expanded Prostate Cancer Index Composite, and the Veterans RAND 12-Item Health Survey. Results: Median followup for survival was 5 years. No significant differences between the treatments were observed for overall survival or metastasis-free survival at the P < .05 threshold. The propensity-adjusted 5-year metastasis-free survival estimates for EBRT + ADT, EBRT + Brachy + ADT, and surgery were 74.6%, 94.8%, and 83.1%, respectively. The EBRT + Brachy + ADT and surgery cohorts had significantly worse mean American Urological Association symptom scores at 6 months than the EBRT + ADT cohort, which resolved by 1 year. Surgical patients had better rectal function scores than EBRT + ADT patients at years 1 to 3, but similar function thereafter. Adjuvant or salvage RT resulted in significant declines in various Expanded Prostate Cancer Index Composite urinary, sexual, and bowel domains, and Veterans RAND 12-Item Health Survey physical but not mental domains. Conclusion: Men with very and/or high-risk localized prostate cancer are likely to require multimodal therapy. The overall differences in survival and long-term QOL are similar for men choosing surgical versus RT pathways. (C) 2020 Elsevier Inc. All rights reserved.