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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

Journal article
Authors P. Stattin
F. Sandin
F. B. Thomsen
H. Garmo
D. Robinson
Ingela Frank-Lissbrant
H. Jonsson
O. Bratt
Published in European Urology
Volume 72
Issue 1
Pages 125-134
ISSN 0302-2838
Publication year 2017
Published at Institute of Clinical Sciences, Department of Oncology
Pages 125-134
Language en
Keywords Prostate cancer, Very high-risk, Radical, Treatment, Semiecologic, Nationwide, Population-based, androgen-deprivation therapy, death certificates, plus orchiectomy, nccn, guidelines, cohort profile, sweden, radiotherapy, register, outcomes, trial, Urology & Nephrology
Subject categories Radiology, Cancer and Oncology, Urology and Nephrology


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 exposurewere in agreement with results fromrandomized trials (PCaMRR: 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: Menwith very high-risk prostate cancer diagnosed and treated in units with the highest exposure to surgery or radiotherapy had a substantially lower mortality. (C) 2016 European Association of Urology. Published by Elsevier B.V.

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