High modality.

Top Line: What’s the universally agreed-upon optimal treatment for high risk prostate cancer, again?

The Study: Good one. This pooled retrospective analysis of over 6000 men treated for high risk prostate cancer at 16 centers aimed to compare survival across treatment modalities. The kicker was, they had to be high risk per NCCN with at least one additional risk factor: primary Gleason 5, cT3b-4 disease, ≥50% of cores positive, or ≥2 high-risk features. They were then divided into three definitive treatment cohorts: [1] radical prostatectomy (53%), [2] external beam radiation (EBRT, 31%), and [3] EBRT with brachytherapy (17%). Across the entire cohort, definitive radiation with (HR 0.78) and without (0.70) brachytherapy was associated with a significantly lower risk of prostate cancer-specific mortality. But before your local urologist cries foul, this was distilled further into comparing outcomes among only those who received “guideline-concordant” care, which was only roughly half of cases in each treatment cohort. For radiation this meant receipt of androgen deprivation therapy (ADT) for at least 24 months with EBRT alone and for at least 12 months with EBRT with brachy. For surgery this meant receiving ADT and/or radiation in the setting of grade group 5 disease, pathologically involved nodes, or upon biochemical recurrence. Alas, there no longer was a difference detected in prostate cancer-specific survival...but. When compared to guideline-concordant prostatectomy, EBRT had half the risk of distant mets (HR 0.48), a risk that was halved again with the addition of brachy (HR 0.25).

TBL: A multi-institutional analysis of all guideline-concordant treatment modalities for high risk prostate cancer demonstrates a substantial reduction in risk of distant mets with the approach of external beam radiation in combo with brachytherapy and at least 12 months ADT.  | Kishan, JAMA Netw Open 2021