COMMENTARY

High-Risk PCa: Start With Radiation, ADT?

Gerald Chodak, MD

Disclosures

May 23, 2016

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Hello. I'm Dr Gerald Chodak for Medscape. Today I want to talk about the management of high-risk prostate cancer with either surgery or combined radiation and androgen deprivation therapy (ADT).

Baker and colleagues[1] conducted a retrospective analysis of 121 patients who were treated with one or the other option from 2001 to 2014. Their follow-up is relatively short—only about 5-6 years—and their analysis only looks at biochemical disease-free survival, both of which are problems. The interesting thing about this study is that we can make some assessment about the relative advantages or disadvantages of these two approaches.

Let me first comment on some of the deficiencies of the study: It's retrospective; the sample size is small; and radiation varied in some ways, with patients receiving 75 Gy to 77 Gy of standard radiation or 70 Gy of hypofractionated radiation therapy. Also, the specific ADT regimen was not clearly defined, and 97% of the patients received ADT for 24 months, even though we know that the best results occur with 28-36 months of therapy.[2,3] On the surgery side, not all of the men had lymph node dissections; of those who did, 18% had a positive lymph node result. When it's all analyzed, we have to say that these results may not be exactly comparable.

Nevertheless, there are certain things to take away from this analysis. Of the patients who ended up getting surgery, two thirds needed external radiation either as salvage or adjuvant therapy, and a significantly higher proportion of patients needed long-term ADT. One of the takeaways from this is that men who have a prostatectomy are more likely to need combination therapy compared with men who simply start off by getting radiation plus ADT. Another problem is that if you start off with surgery, you have a higher likelihood of getting metastatic disease, even at the 5-year mark.

It really doesn't seem that surgery as a first option for men with high-risk disease makes a lot of sense, because only a small fraction of them will end up being treated with surgery alone. So, to start off and get surgery followed by radiation—which is likely to have a higher risk for side effects and higher risk for metastatic disease—doesn't seem to make a lot of sense.

I think that surgeons are going to have to accept that their likelihood of curing men with surgery alone for high-risk disease is not as good as it is with radiation plus ADT. Radiation plus ADT is more likely to offer finite treatment as opposed to surgery, which might require long-term ADT.

Although this was not a randomized controlled trial—and a randomized controlled trial clearly would be necessary to answer the question of surgery vs radiation plus ADT in these patients—this study still provides important information that allows us to determine that surgery as the start of treatment for high-risk disease has more disadvantages than starting with radiation therapy plus ADT for a defined amount of time.

I look forward to your comments. Thank you.

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