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Association of Radical Local Treatment with Mortality in Men with Very High-risk Prostate Cancer : A Semiecologic, Nationwide, Population-based Study

Stattin, Pär; Sandin, Fredrik; Thomsen, Frederik Birkebæk; Garmo, Hans; Robinson, David; Lissbrant, Ingela Franck; Jonsson, Håkan LU and Bratt, Ola LU (2017) In European Urology 72(1). p.125-134
Abstract

Background: Current guidelines recommend androgen deprivation therapy only for men with very high-risk prostate cancer (PCa), but there is little evidence to support this stance. Objective: To investigate the association between radical local treatment and mortality in men with very high-risk PCa. Design, setting, and participants: Semiecologic study of men aged <80 yr within the Prostate Cancer data Base Sweden, diagnosed in 1998-2012 with very high-risk PCa (local clinical stage T4 and/or prostate-specific antigen [PSA] level 50-200. ng/ml, any N, and M0). Men with locally advanced PCa (local clinical stage T3 and PSA level <50. ng/ml, any N, and M0) were used as positive controls. Intervention: Proportion of men who received... (More)

Background: Current guidelines recommend androgen deprivation therapy only for men with very high-risk prostate cancer (PCa), but there is little evidence to support this stance. Objective: To investigate the association between radical local treatment and mortality in men with very high-risk PCa. Design, setting, and participants: Semiecologic study of men aged <80 yr within the Prostate Cancer data Base Sweden, diagnosed in 1998-2012 with very high-risk PCa (local clinical stage T4 and/or prostate-specific antigen [PSA] level 50-200. ng/ml, any N, and M0). Men with locally advanced PCa (local clinical stage T3 and PSA level <50. ng/ml, any N, and M0) were used as positive controls. Intervention: Proportion of men who received prostatectomy or full-dose radiotherapy in 640 experimental units defined by county, diagnostic period, and age at diagnosis. Outcome measurements and statistical analysis: PCa and all-cause mortality rate ratios (MRRs). Results and limitations: Both PCa and all-cause mortality were half as high in units in the highest tertile of exposure to radical local treatment compared with units in the lowest tertile (PCa MRR: 0.51; 95% confidence interval [CI], 0.28-0.95; and all-cause MRR: 0.56; 95% CI, 0.33-0.92). The results observed for locally advanced PCa for highest versus lowest tertile of exposure were in agreement with results from randomized trials (PCa MRR: 0.75; 95% CI, 0.60-0.94; and all-cause MRR: 0.85; 95% CI, 0.72-1.00). Although the semiecologic design minimized selection bias on an individual level, the effect of high therapeutic activity could not be separated from that of high diagnostic activity. Conclusions: The substantially lower mortality in units with the highest exposure to radical local treatment suggests that radical treatment decreases mortality even in men with very high-risk PCa for whom such treatment has been considered ineffective. Patient summary: Men with very high-risk prostate cancer diagnosed and treated in units with the highest exposure to surgery or radiotherapy had a substantially lower mortality. The cause-specific and all-cause mortality among men diagnosed with very high-risk prostate cancer in experimental units with high use of radical local treatment were half the rates of men diagnosed in experimental units with low use.

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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Nationwide, PCBaSe, Population-based, Prostate cancer, Radical, Semiecologic, Treatment, Very high-risk
in
European Urology
volume
72
issue
1
pages
125 - 134
publisher
Elsevier
external identifiers
  • scopus:84997207163
  • wos:000403205900026
ISSN
0302-2838
DOI
10.1016/j.eururo.2016.07.023
language
English
LU publication?
yes
id
333030ba-a9a8-4814-bbe5-b1e63c03ac17
date added to LUP
2016-12-30 14:17:25
date last changed
2018-11-13 10:55:22
@article{333030ba-a9a8-4814-bbe5-b1e63c03ac17,
  abstract     = {<p>Background: Current guidelines recommend androgen deprivation therapy only for men with very high-risk prostate cancer (PCa), but there is little evidence to support this stance. Objective: To investigate the association between radical local treatment and mortality in men with very high-risk PCa. Design, setting, and participants: Semiecologic study of men aged &lt;80 yr within the Prostate Cancer data Base Sweden, diagnosed in 1998-2012 with very high-risk PCa (local clinical stage T4 and/or prostate-specific antigen [PSA] level 50-200. ng/ml, any N, and M0). Men with locally advanced PCa (local clinical stage T3 and PSA level &lt;50. ng/ml, any N, and M0) were used as positive controls. Intervention: Proportion of men who received prostatectomy or full-dose radiotherapy in 640 experimental units defined by county, diagnostic period, and age at diagnosis. Outcome measurements and statistical analysis: PCa and all-cause mortality rate ratios (MRRs). Results and limitations: Both PCa and all-cause mortality were half as high in units in the highest tertile of exposure to radical local treatment compared with units in the lowest tertile (PCa MRR: 0.51; 95% confidence interval [CI], 0.28-0.95; and all-cause MRR: 0.56; 95% CI, 0.33-0.92). The results observed for locally advanced PCa for highest versus lowest tertile of exposure were in agreement with results from randomized trials (PCa MRR: 0.75; 95% CI, 0.60-0.94; and all-cause MRR: 0.85; 95% CI, 0.72-1.00). Although the semiecologic design minimized selection bias on an individual level, the effect of high therapeutic activity could not be separated from that of high diagnostic activity. Conclusions: The substantially lower mortality in units with the highest exposure to radical local treatment suggests that radical treatment decreases mortality even in men with very high-risk PCa for whom such treatment has been considered ineffective. Patient summary: Men with very high-risk prostate cancer diagnosed and treated in units with the highest exposure to surgery or radiotherapy had a substantially lower mortality. The cause-specific and all-cause mortality among men diagnosed with very high-risk prostate cancer in experimental units with high use of radical local treatment were half the rates of men diagnosed in experimental units with low use.</p>},
  author       = {Stattin, Pär and Sandin, Fredrik and Thomsen, Frederik Birkebæk and Garmo, Hans and Robinson, David and Lissbrant, Ingela Franck and Jonsson, Håkan and Bratt, Ola},
  issn         = {0302-2838},
  keyword      = {Nationwide,PCBaSe,Population-based,Prostate cancer,Radical,Semiecologic,Treatment,Very high-risk},
  language     = {eng},
  number       = {1},
  pages        = {125--134},
  publisher    = {Elsevier},
  series       = {European Urology},
  title        = {Association of Radical Local Treatment with Mortality in Men with Very High-risk Prostate Cancer : A Semiecologic, Nationwide, Population-based Study},
  url          = {http://dx.doi.org/10.1016/j.eururo.2016.07.023},
  volume       = {72},
  year         = {2017},
}