Surgery Versus Radiotherapy for Clinically-localized Prostate Cancer: A Systematic Review and Meta-analysis

Christopher J D Wallis; Refik Saskin; Richard Choo; Sender Herschorn; Ronald T Kodama; Raj Satkunasivam; Prakesh S Shah; Cyril Danjoux; Robert K Nam

doi:10.1016/j.eururo.2015.11.010

Surgery Versus Radiotherapy for Clinically-localized Prostate Cancer: A Systematic Review and Meta-analysis

Eur Urol. 2016 Jul;70(1):21-30. doi: 10.1016/j.eururo.2015.11.010. Epub 2015 Dec 15.

Authors

Christopher J D Wallis¹, Refik Saskin², Richard Choo³, Sender Herschorn⁴, Ronald T Kodama⁴, Raj Satkunasivam⁴, Prakesh S Shah⁵, Cyril Danjoux⁶, Robert K Nam⁷

Affiliations

¹ Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Canada; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
² Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Institute of Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada.
³ Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
⁴ Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Canada; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.
⁵ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
⁶ Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
⁷ Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Canada; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. Electronic address: robert.nam@utoronto.ca.

PMID: 26700655
DOI: 10.1016/j.eururo.2015.11.010

Abstract

Context: To date, there is no Level 1 evidence comparing the efficacy of radical prostatectomy and radiotherapy for patients with clinically-localized prostate cancer.

Objective: To conduct a meta-analysis assessing the overall and prostate cancer-specific mortality among patients treated with radical prostatectomy or radiotherapy for clinically-localized prostate cancer.

Evidence acquisition: We searched Medline, EMBASE, and the Cochrane Library through June 2015 without year or language restriction, supplemented with hand search, using Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. We used multivariable adjusted hazard ratios (aHRs) to assess each endpoint. Risk of bias was assessed using the Newcastle-Ottawa scale.

Evidence synthesis: Nineteen studies of low to moderate risk of bias were selected and up to 118 830 patients were pooled. Inclusion criteria and follow-up length varied between studies. Most studies assessed patients treated with external beam radiotherapy, although some included those treated with brachytherapy separately or with the external beam radiation therapy group. The risk of overall (10 studies, aHR 1.63, 95% confidence interval 1.54-1.73, p<0.00001; I(2)=0%) and prostate cancer-specific (15 studies, aHR 2.08, 95% confidence interval 1.76-2.47, p < 0.00001; I(2)=48%) mortality were higher for patients treated with radiotherapy compared with those treated with surgery. Subgroup analyses by risk group, radiation regimen, time period, and follow-up length did not alter the direction of results.

Conclusions: Radiotherapy for prostate cancer is associated with an increased risk of overall and prostate cancer-specific mortality compared with surgery based on observational data with low to moderate risk of bias. These data, combined with the forthcoming randomized data, may aid clinical decision making.

Patient summary: We reviewed available studies assessing mortality after prostate cancer treatment with surgery or radiotherapy. While the studies used have a potential for bias due to their observational design, we demonstrated consistently higher mortality for patients treated with radiotherapy rather than surgery.

Keywords: Brachytherapy; Mortality; Prostatectomy; Prostatic neoplasms; Radiotherapy; Retropubic; Survival.

Publication types

Comparative Study
Meta-Analysis
Review
Systematic Review

MeSH terms

Brachytherapy
Humans
Male
Prostatectomy
Prostatic Neoplasms / mortality
Prostatic Neoplasms / pathology
Prostatic Neoplasms / radiotherapy*
Prostatic Neoplasms / surgery*
Radiotherapy, Intensity-Modulated
Survival Rate