Refers to article:
A Competing-Risks Analysis of Survival After Alternative Treatment Modalities for Prostate Cancer Patients: 1988–2006
Accepted 5 October 2010
January 2011 (Vol. 59, Issue 1, pages 88 - 95)
Abdollah et al analyzed utilization and survival by varying treatment modalities for prostate cancer . The authors noted several trends, including increasing utilization of radiation therapy (RT) and observation compared to radical prostatectomy (RP). Unfortunately, this population-based study could not provide data on utilization or outcomes from robotic versus retropubic prostatectomies, external beam RT versus brachytherapy, or observation versus active surveillance.
The authors report that RP provides superior survival rates in most patients, and they dispel the possibility that RP benefits may be related to patient selection. The authors state that “no clinically meaningful differences were recorded” among patients undergoing RP, RT, or observation. However, patient age significantly differed by modality, with the proportion of patients ≥70 yr undergoing RT nearly triple that for RP (51.5% vs 17.9%, p < 0.001). Increased 30-d mortality after RP is well established in older patients or in patients who have comorbidities. Furthermore, poor correlation between causes of death on death certificates and true causes of death in men with prostate cancer has been described . Because older men in the study by Abdollah et al were more likely to receive RT and because survival decreased with age, causes of death among RT patients may have been incorrectly attributed to prostate cancer instead of other-cause mortality (OCM) more often than for RP patients.
Abdollah et al presented no data comparing patient comorbidities by treatment modality. The authors assert, “Because our CSM [cancer-specific mortality] is adjusted to OCM, it is unlikely that the difference in comorbidities among the three groups affected CSM results.” With this flawed reasoning, the authors purport that observation should be given priority over RT when RP is not an option among patients ≤59 yr of age. However, because OCM among RT patients was higher than among RP patients, RT candidates likely were in poorer health. Advanced patient age and medical comorbidities are well-described adverse prognosticators for both OCM and CSM , , , and .
Although the authors mention that the apparent benefit of RP may be partially attributable to reclassification of some patients into higher-stage groups based on pathologic stages, this point should not be understated. Among 4035 RP patients at Memorial Sloan-Kettering Cancer Center and Baylor College of Medicine, Gleason upgrading from biopsy to RP occurred in 35–45% of patients and upstaging from cT1-T2 to pT3 occurred in 30% .
Although Abdollah et al  report groupings of diagnosis by year, they do not provide subset analyses for survival rates by year. Just as there have been improvements in surgical techniques and outcomes, increasing use of hormonal therapy has improved survival of intermediate- and high-risk patients when combined with RT, and more recent radiation dose escalation has improved biochemical relapse-free survival.
The authors concede that CSM is estimated only after accounting for OCM based on competing-risks methodology. However, the true CSM benefit of RP or RT may be difficult to access and less than this study suggests because OCM is significantly higher than CSM for prostate cancer  and . With no randomization trials on the horizon, better controlling for patient age and comorbidities is necessary when attempting to compare survival outcomes between RP and RT.
Conflicts of interest
The authors have nothing to disclose.
-  F. Abdollah, M. Sun, R. Thuret, et al. A competing-risks analysis of survival after alternative treatment modalities for prostate cancer patients: 1988–2006. Eur Urol. 2011;59:88-95
-  M.N. Fouad, C.P. Mayo, E.M. Funkhouser, I. Hall, D.A. Urban, C.I. Kiefe. Comorbidity independently predicted death in older prostate cancer patients, more of whom died with than from their disease. J Clin Epidemiol. 2004;57:721-729
-  P.C. Albertsen, D.G. Fryback, B.E. Storer, T.F. Kolon, J. Fine. The impact of co-morbidity on life expectancy among men with localized prostate cancer. J Urol. 1996;156:127-132
-  A.V. D’Amico, M.H. Chen, A.A. Renshaw, M. Loffredo, P.W. Kantoff. Causes of death in men undergoing androgen suppression therapy for newly diagnosed localized or recurrent prostate cancer. Cancer. 2008;113:3290-3297
-  A. Nanda, M.H. Chen, B.J. Moran, et al. Predictors of prostate cancer-specific mortality in elderly men with intermediate-risk prostate cancer treated with brachytherapy with or without external beam radiation therapy. Int J Radiat Oncol Biol Phys. 2010;77:147-152
-  L. Richstone, F.J. Bianco, H.H. Shah, et al. Radical prostatectomy in men aged > or =70 years: effect of age on upgrading, upstaging, and the accuracy of a preoperative nomogram. BJU Int. 2008;101:541-546
a National Institutes of Health, National Cancer Institute, Radiation Oncology Branch, Bethesda, MD, USA
b Simone Protective Cancer Center, Lawrenceville, NJ, USA
Corresponding author. Simone Protective Cancer Center, 123 Franklin Corner Road, Suite 108, Lawrenceville, NJ, USA. Tel. +1 609 896 2646; Fax: +1 609 895 1515.
© 2011 Published by Elsevier B.V.