Surgery Better Than Radiation in Localized Prostate Cancer

Kate Johnson

March 22, 2013

MILAN, Italy — Radical prostatectomy offers better survival than radiotherapy for men with localized prostate cancer, according to an observational study of 34,515 men.

"This suggests that surgery has an edge for most of these men" over radiotherapy, said lead investigator Prasanna Sooriakumaran, MD, from Karolinska University Hospital in Stockholm, Sweden. The findings should have an impact on daily clinical practice, he noted.

Dr. Sooriakumaran presented the study, along with senior investigator Peter Wiklund, MD, also from Karolinska University, in a late-breaking session here at the the European Association of Urology (EAU) 28th Annual Congress, where it won second prize.

Data were drawn from the National Prostate Cancer Registry in Sweden, which includes almost all Swedish men with prostate cancer initially treated from 1996 to 2000 with either surgery (n = 21,533) or radiotherapy (n = 12,982) and no hormone therapy.

The registry collects data on a wide range of covariates, including age, prostate-specific antigen (PSA) level, stage of disease, Gleason score, Charlson comorbidity index, marital status, educational status, and socioeconomic status, said Dr. Sooriakumaran

The median follow-up for both the surgery and radiation groups was 6 years, he reported.

The investigators calculated cumulative incidence curves for prostate cancer mortality and other-cause mortality. They also calculated competing-risk (radiotherapy vs surgery) regression hazard ratios (HRs) without adjustment and then with propensity score and traditional adjustments.

There was an overall unadjusted 3-fold increased risk for death in the radiotherapy group, compared with the surgery group (P < .001), Dr. Wiklund reported. The propensity score and traditional covariate adjusted HRs were 1.76 and 1.77, respectively (P < 0.001 for both).

The risk for death was higher for radiotherapy than for surgery in the low-, intermediate-, and high-risk categories. It was only in the metastatic category that the risk for death equalized for the 2 therapies.

Table. Risk for Death With Radiotherapy, Compared With Surgery

Hazard Ratio by Risk Category Risk for Death P value
Low-risk category    
Unadjusted HR 2.15 <.001
Propensity score adjusted HR 1.91 <.011
Traditional covariate adjusted HR 2.03 <.007
Intermediate-risk category    
Unadjusted HR 1.95 <.001
Propensity score adjusted HR 1.77 <.001
Traditional covariate adjusted HR 1.77 <.001
High-risk category    
Unadjusted HR 1.69 <.001
Propensity score adjusted HR 1.50 <.001
Traditional covariate adjusted HR 1.63 <.001
Metastatic category    
Unadjusted HR 1.04 .835
Propensity score adjusted HR 0.76 .231
Traditional covariate adjusted HR 0.65 .081


This study could lead to the increasing use of surgery over radiation for patients with localized disease, said Dr. Sooriakumaran. He noted that for patients with locally advanced and metastatic disease, the 2 therapies appear to be equivalent.

An inevitable limitation of this study is that it compares older forms of radiation and surgery, which have since evolved since the 1996 to 2000 study period.

"Radiation oncologists will say that radiation has changed completely since then, but that's a moot point because so has surgery," he said.

"The caveat with studies like this is always that they are retrospective. It is important to be very careful about the adequacy of risk adjustment, among other issues," said Matthew Cooperberg, MD, from the University of California at San Francisco, who was asked by Medscape Medical News to comment on the study.

However, the findings "are entirely consistent with a growing number of carefully performed retrospective studies that have been published in the past few years," he noted.

"These studies, from both academic- and community-based data registries, consistently suggest that for men with higher-risk prostate cancer, we see both statistically significant and clinically meaningful differences in mortality, with mortality end points in all papers published to date favoring surgery over external-beam radiation," he explained.

"The fact is, the best way to treat aggressive high-risk prostate cancer is likely multimodal," Dr. Cooperberg said, "and for many patients includes surgery, radiation, and systemic therapy."

Dr. Sooriakumaran, Dr. Wiklund, and Dr. Cooperberg have disclosed no relevant financial relationships.

European Association of Urology (EAU) 28th Annual Congress: Abstract 192. Presented March 18, 2013.