Abstract
PurposeTo assess the outcomes of high-dose-rate (HDR) brachytherapy and hypofractionated external beam radiation therapy (EBRT) combined with long-term androgen deprivation therapy (ADT) in very-high-risk (VHR) versus high-risk (HR) prostate cancer (PCa), as defined in the National Comprehensive Cancer Network (NCCN) criteria.MethodsData from 338 consecutive HR or VHR PCa patients who had undergone this tri-modal therapy between 2005 and 2018 were retrospectively analyzed. Biochemical recurrence (BCR)-free, progression-free, overall, and cancer-specific survival (BCRFS/PFS/OS/CSS) rates were analyzed using the Kaplan–Meier method and Wilcoxon test. Cox regression models were used to evaluate candidate prognostic factors for survival. C‑indexes were used to assess model discrimination.ResultsWithin a median follow-up of 84 months, 68 patients experienced BCR, 58 had disease progression including only 3 with local progression, 27 died of any cause, and 2 died from PCa. The 5‑year BCRFS, PFS, OS, and CSS rates were 82.2% (HR 86.5%; VHR 70.0%), 90.0% (HR 94.3%; VHR 77.6%), 95.7% (HR, 97.1%; VHR, 91.8%), and 99.6% (HR, 100%; VHR, 98.0%), respectively. In multivariable analyses that adjusted for standard clinicopathologic features, the risk subclassification was associated both PFS and OS (p = 0.0003 and 0.001, respectively). Adding the risk subclassification improved the accuracy of models in predicting BCRFS, PFS, and OS.ConclusionWhile the outcome of this trimodal approach appears favorable, VHR PCa patients had significantly worse oncological outcomes than those with HR PCa. The NCCN risk subclassification should be integrated into prognostic tools to guide risk stratification, treatment, and follow-up for unfavorable PCa patients receiving this trimodal therapy.
Highlights
Materials and methodsIn the 2014 version, the National Comprehensive Cancer Network (NCCN) guidelines for clinically localized prostate cancer (PCa) refined their definition of unfavorable-risk disease into very-high-risk (VHR) and high-risk (HR) subsets [1]
Dose escalation offers a greater benefit in terms of biochemical recurrence-free survival (BCRFS), especially in higher-risk PCa [3]
Given that there is a paucity of evidence about the benefit of this trimodal approach, especially in the VHR PCa subpopulation, the purpose of this study was to report treatment outcomes in patients with VHR PCa compared to those with HR
Summary
In the 2014 version, the National Comprehensive Cancer Network (NCCN) guidelines for clinically localized prostate cancer (PCa) refined their definition of unfavorable-risk disease into very-high-risk (VHR) and high-risk (HR) subsets [1]. The criteria for VHR include clinical stage ≥T3b or primary Gleason pattern 5 or ≥5 biopsy cores with a Gleason score (GS) of 8–10. The clinical management of these patients is complex, given that there are multiple options to deliver the optimal local control with the lowest risk of metastatic relapse [2]. Several treatment options are currently available for definitive radiotherapy in unfavorable-risk PCa [1]. In addition to conventional external beam radiation therapy (EBRT) such as 3D conformal radiotherapy and intensitymodulated radiotherapy (IMRT), brachytherapy boost with low-dose-rate or high-dose-rate (HDR-BT) has become a decent option. Dose escalation offers a greater benefit in terms of biochemical recurrence-free survival (BCRFS), especially in higher-risk PCa [3]
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