Introduction:

Prostate cancer is traditionally regarded as a disease of older men. However, of the 236,659 new cases of prostate cancer reported in US in 2021, 6% of prostate cancer cases were diagnosed among men aged 45 to 54 years. In this younger population, treatment decisions carry long-term clinical and quality-of-life implications. Well-established definitive treatment modalities for prostate cancer are Radical Prostatectomy (RP) and External Beam Radiation Therapy with Androgen Deprivation Therapy (XRT + ADT). However, studies comparing effectiveness of these modalities in the younger population remain limited. Using the National Cancer Database (NCDB), this study compares the patient characteristics and survival outcomes associated with RP to XRT + ADT.

Methods:

Within the 2022 NCDB, individuals which received RP or XRT + ADT as their initial treatment course were identified. XRT + ADT was defined as external beam radiation therapy (EBRT) to the prostate/pelvis, with ADT initiated within 90 days. Clinical, demographic, and pathologic characteristics were obtained and propensity score matching was used to balance cohort characteristics between treatment modalities (covariates include age, comorbidity, clinical stage, and Gleason score). Multiple logistic regression models were used to predict the receipt of XRT + ADT as primary treatment and the receipt of any secondary therapy (ST). ST was defined as XRT ± ADT following initial RP. Survival analysis was performed using the Cox Proportional Hazards Model and the Kaplan-Meier Method.

Results:

A total of 155,644 men were analyzed; 94.5% underwent RP first and 5.45% underwent XRT + ADT first. Following propensity score matching, 16,966 patients were analyzed. In a multivariable logistic regression model predicting treatment, XRT + ADT group was more likely to have higher clinical T stage and Gleason grade. Patients with higher income and private insurance had greater odds of receiving XRT + ADT. Within the RP group, 1,830 (21.6%) received secondary therapy (XRT ± ADT). Survival analysis showed that the RP group fared better (86% OS at 5 years versus 82.4%), but RP + ST patients fared similarly to XRT + ADT group. When controlling for patient demographics (including age) and disease characteristics (including clinical stage), the resulting hazard ratio for the XRT + ADT group compared to RP was 1.67 (95% CI 1.54 – 1.81, P < 0.001), indicating worse survival outcomes for these patients.

Conclusion:

These findings suggest that after propensity score matching, RP offers survival advantage. For those patients requiring secondary/salvage treatment after RP, survival mirrors that of primary XRT+ADT and still justifies the role of primary surgery in this young patient population.

Funding: N/A