New(?) study Nov 2018, maxRT vs maxRP for high risk

Have we already discussed this study here? If so, my apologies.

If not, here you go. I found it to be an unusually hard study to read. There are so many adjustments made, including one for "propensity score" that it is extra challenging for me to follow all the details. But to keep it simple, here is the gist of it as summarized by the authors. Comparing prostate cancer–specific mortality (PCSM) and all-cause mortality (ACM) risk:
https://jamanetwork.com/journals/jamaoncology/fullarticle/2713856?guestaccesskey=b6e15915-e323-4531-ace2-e55e6d3103b8&utm_source=silverchair&utm_campaign=jama_network&utm_content=weekly_highlights&cmp=1&utm_medium=email

Somebody said...

Key Points

Question Can treatment with radical prostatectomy, adjuvant external beam radiotherapy, and androgen deprivation therapy (termed MaxRP) or external beam radiotherapy, brachytherapy, and androgen deprivation therapy (termed MaxRT) in men with Gleason score 9-10 prostate cancer provide similar survival outcomes?

Findings Among 639 men, this cohort study found no significant difference after MaxRP or MaxRT in prostate cancer–specific and all-cause death risk , with plausibility indexes for equivalence of 76.75% for prostate cancer–specific mortality risk and 77.97% for all-cause mortality risk.

Meaning It is plausible that treatment with MaxRP or MaxRT for men with Gleason score 9-10 prostate cancer provides equivalent survival outcomes.
Abstract

Importance It is unknown how treatment with radical prostatectomy (RP) and adjuvant external beam radiotherapy (EBRT), androgen deprivation therapy (ADT), or both (termed MaxRP) compares with treatment with EBRT, brachytherapy, and ADT (termed MaxRT).

Objective To investigate whether treatment of Gleason score 9-10 prostate cancer with MaxRP vs MaxRT was associated with prostate cancer–specific mortality (PCSM) and all-cause mortality (ACM) risk.

Design, Setting, and Participants The study cohort comprised 639 men with clinical T1-4,N0M0 biopsy Gleason score 9-10 prostate cancer. Between February 6, 1992, and April 26, 2013, a total of 80 men were consecutively treated with MaxRT at the Chicago Prostate Cancer Center, and 559 men were consecutively treated with RP and pelvic lymph node dissection at the Martini-Klinik Prostate Cancer Center. Follow-up started on the day of prostate EBRT or RP and concluded on October 27, 2017.

Exposures Of the 559 men managed with RP and pelvic lymph node dissection, 88 (15.7%) received adjuvant EBRT, 49 (8.8%) received ADT, and 50 (8.9%) received both.

Main Outcomes and Measures Treatment propensity score–adjusted risk of PCSM and ACM and the likelihood of equivalence of these risks between treatments using a plausibility index.

Results The cohort included 639 men, with a mean (SD) age of 65.83 (6.52) years. After median follow-ups of 5.51 years (interquartile range, 2.19-6.95 years) among 80 men treated with MaxRT and 4.78 years (interquartile range, 4.01-6.05 years) among 559 men treated with RP-containing treatments, 161 men had died, 106 (65.8%) from prostate cancer. There was no significant difference in the risk of PCSM (adjusted hazard ratio, 1.33; 95% CI, 0.49-3.64; P = .58) and ACM (adjusted hazard ratio, 0.80; 95% CI, 0.36-1.81; P = .60) when comparing men who underwent MaxRP vs MaxRT, with plausibility indexes for equivalence of 76.75% for the end point of the risk of PCSM and 77.97% for the end point of the risk of ACM. Plausibility indexes for all other treatment comparisons were less than 63%.

Conclusions and Relevance Results of this study suggest that it is plausible that treatment with MaxRP or MaxRT for men with biopsy Gleason score 9-10 prostate cancer can lead to equivalent risk of PCSM and ACM .

I just saw this: "Some points require further discussion. First, while not significant, men undergoing RP plus adjuvant RT had an AHR for PCSM and ACM risk less than 1.0, which can be explained by the more favorable baseline distribution of prostate cancer prognostic factors in men undergoing RP plus adjuvant RT vs MaxRT, in addition to the significantly shorter median follow-up of 3.87 vs 5.51 years (P = .03), providing less time to observe deaths. Moreover, when treatment with RP plus adjuvant RT was evaluated for possible equivalence with MaxRT using the plausibility index, the values were 58.24% and 62.32% for the risk of PCSM and ACM, respectively, which were lower compared with the respective values of 76.75% and 77.97% for men treated with MaxRP.

Second, while a prior study22 has shown that at least 75% of men undergoing RP for biopsy Gleason score 9-10 prostate cancer will have at least 1 adverse pathologic factor at RP (ie, extraprostatic extension, seminal vesicle invasion, R1, or N1) and thus have an indication for adjuvant EBRT and/or ADT, only 33.5% (187 of 559) of men received adjuvant EBRT, ADT, or both in the present study. The reason for the low use of adjuvant EBRT in the post-RP setting arises from the concerns regarding overtreatment in the current era in which PSA monitoring after RP is routinely practiced and early salvage EBRT at the time of PSA failure can occur. "