Radical Prostatectomy Provides Better Outcomes Than Radiation in cN1 Prostate Cancer

There is controversy about whether radical prostatectomy (RP) or radiation therapy (RT) provides a better survival benefit in patients with prostate cancer (PCa) and clinically positive nodes (cN1). Most retrospective reports are limited due to selection bias, where patients in poor health are more frequently treated with RT.

New research by Shane Tinsley and colleagues presented at the European Association of Urology Congress 2024 compared prostate cancer-specific mortality (PCSM) in cN1 patients with PCa who received RP versus RT in an other-cause mortality (OCM)-weighted cohort.

Data from patients with cN1 PCa at diagnosis between 2004 and 2017 were gathered from the Surveillance, Epidemiology, and End Results database. Each patient was treated with RP or RT. A Cox regression model calculated the 10-year OCM risk, and a competing risk multivariate model was used to determine the impact of treatment type on PCSM.

A total of 5778 patients were included in the study, with 4739 (82.02%) undergoing RP and 1039 (17.98%) undergoing RT. The median follow-up was 4.7 years. Statistically significant differences in OCM were seen between RP and RT patients in the unweighted cohort, but this difference disappeared in the weighted cohort.

Based on cumulative incidence function, the 10-year PCSM rate was 32.2% (95% CI, 27.6%-35.6%) for patients treated with RT versus 17.1% (95% CI, 15.9%-19.0%) for those treated with RP (P<.001).

cN1 patients with PCa who undergo initial treatment with RT have worse PCSM outcomes than those treated with RP. This trial serves as the first study to compare treatment cohorts after reducing selection bias in “real-world” practice by weighing models with calculated OCM.