After keeping quiet and watching this discussion (with some group-think developing), and closely reviewing what's publicly available through the link to Dr. Kishan's study, I have a few observations.
The article has some significant limitations that may be glossed over a bit too much. The full article is $35, and I'm not going to buy it to go further into it, though perhaps someone will.
1) It's a retrospective study. These are always of limited value and are typically weighted with caution. Selection and confirmation bias are hard to avoid. Prospective, randomized studies have far more value. Here's a Wiki about
retrospective studies, for reference:
/en.wikipedia.org/wiki/Retrospective_cohort_study2) No mention of relative toxicities, either short or long term.
3) Very different cohort size between the treatments. Statistical effect unclear.:
170 were treated with radical prostatectomy (RP).
230 were treated with EBRT only.
87 were treated with EBRT + BT, and most of the BT was high dose rate.
4) The EBRT group were treated to a median dose of 76.4 Gy, so half more, half less. Actual distribution not provided, so how many were how much less? Can't tell. Today's dose is commonly somewhat higher; mine was 79.2 Gy for example. Rarely above 81 Gy for EBRT due to toxicity. That's also why SBRT may be better due to the alpha/beta ratio of prostate tissue. A lower dose at a higher rate may have a higher effective dose, if I understand correctly.
5) And, to the outcome statistics. Caution here. Correlations without causality, most were not significant.
A) The 10-year biochemical recurrence rates (BCRs): No statement of significant difference between EBRT vs EBRT+BT. Cleverly worded that both were significantly different from RP, but no mention relative to each other.
No statistically significant advantage for EBRT+BPB) Percentages of patients who began lifelong ADT after therapy failure: Same thing, no statement of significant difference between EBRT vs EBRT+BT. Both different from RP, but not each other.
No statistically significant advantage for EBRT+BPC) The 10-year rates of distant metastases: Differences between EBRT + BT and the two others were statistically significant, while the differences between RP and EBRT were not.
Advantage EBRT+BPD) The 10-year rates of prostate cancer-specific mortality:
No statistically significant advantage for EBRT+BPE) The 10-year rates of overall survival:
No statistically significant advantage for EBRT+BPSo, out of 5 specific metrics, only one showed statistical significance. This is a rather big deal, since it means the differences observed cannot be proven different from random occurrence. Much speculative commenting in the article's text.
The one significant metric, regarding different outcome for distant metastases, is very interesting. The causality is unclear though, since I've heard for quite some time that distant metastases are more likely from previously undetected micrometastases that develop over the years, rather than spreading from the irradiated prostate itself.
In conclusion, I don't find this article very convincing, and its rah-rah nature makes the inherent biases even more suspect. It might help marketing BT services in addition to EBRT if one isn't too statistically critical. Maybe it makes the case that adding BT allows shortening the ADT sentence from 24 months to 8 months, a reduction for which I'd sure be in favor! That's not really what they were saying, yet 4 of 5 metrics don't show any significant difference in outcome so maybe it's not too much of a stretch.
So, if one can, or one cannot, receive the "triple play" treatment option, apart from one metric this article doesn't actually demonstrate it to be definitively better than traditional EBRT+ADT. The shorter course of ADT is attractive, to be sure.
Good science is hard and expensive to do. This study doesn't really qualify as "good science", in my humble opinion.