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Comparison of the Efficacy of Local Therapies for Localized Prostate Cancer in the Prostate-Specific Antigen Era: A Large Single-Institution Experience With Radical Prostatectomy and External-Beam Radiotherapy

From the Departments of Radiation Oncology and Urology, Cleveland Clinic Foundation, Cleveland, OH.

Address reprint requests to Patrick Kupelian, MD, Department of Radiation Oncology, Desk T28, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195; email: kupelip{at}ccf.org

PURPOSE: To review biochemical relapse-free survival (bRFS) rates after either external-beam radiotherapy (RT) or radical prostatectomy (RP) for localized prostate cancer.

PATIENTS AND METHODS: All 1,682 patients had pretreatment prostate-specific antigen (PSA) levels and biopsy Gleason scores (bGS) assigned. No adjuvant therapy was administered after local treatment. RP was the treatment in 1,054 patients (63%) and RT in 628 patients (37%). Median follow-up was 51 months (range, 1 to 134). The median follow-up for RP versus RT patients was 50.5 v 51.0 months. Biochemical relapse was considered detectable PSA levels (> 0.2 ng/mL) in RP patients and three consecutive rising PSA levels in RT patients. The analysis was repeated with a more stringent definition of biochemical control after either RP or RT—namely, reaching and maintaining a PSA level 0.5 ng/mL—and excluding patients receiving any androgen deprivation (AD).

RESULTS: Eight-year bRFS rates for RP versus RT were 72% and 70%, respectively (P = .010). Multivariate analysis indicated T stage (P < .001), pretreatment PSA (P < .001), bGS (P < .001), year of therapy (P < .001), and neoadjuvant AD (P = .019) to be the only independent predictors of relapse. Age (P = .78), race (P = .29), prior transurethral resection of prostate (P = .81), and treatment modality (P = .96) were not independent predictors of treatment failure. Fifty-one percent of RP patients had favorable tumors (T1 to T2A, pretreatment PSA 10 ng/mL, bGS 7), compared with only 34% of RT patients (P < .001). Repeat analysis with a stringent definition of biochemical failure and excluding patients receiving AD indicated no impact of treatment modality on outcome.

CONCLUSION: Eight-year biochemical failure rates were identical between RT and RP in any subgroup. Outcome is determined mainly by pretreatment PSA levels, bGS, clinical T stage, and, for RT patients, radiation dose.

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