Primary radiotherapy versus radical prostatectomy for high-risk prostate cancer: a decision analysis

BACKGROUND:

Two evidence‐based therapies exist for the treatment of high‐risk prostate cancer (PCA): external‐beam radiotherapy (RT) with hormone therapy (H) (RT + H) and radical prostatectomy (S) with adjuvant radiotherapy (S + RT). Each of these strategies is associated with different rates of local control, distant metastasis (DM), and toxicity. By using decision analysis, the authors of this report compared the quality‐adjusted life expectancy (QALE) between men with high‐risk PCA who received RT + H versus S + RT versus a hypothetical trimodality therapy (S + RT + H).

METHODS:

The authors developed a Markov model to describe lifetime health states after treatment for high‐risk PCA. Probabilities and utilities were extrapolated from the literature. Toxicities after radiotherapy were based on intensity‐modulated radiotherapy series, and patients were exposed to risks of diabetes, cardiovascular disease, and fracture for 5 years after completing H. Deterministic and probabilistic sensitivity analyses were performed to model uncertainty in outcome rates, toxicities, and utilities.

RESULTS:

RT + H resulted in a higher QALE compared with S + RT over a wide range of assumptions, nearly always resulting in an increase of >1 quality‐adjusted life year with outcomes highly sensitive to the risk of increased all‐cause mortality from H. S + RT + H typically was superior to RT + H, albeit by small margins (<0.5 quality‐adjusted life year), with results sensitive to assumptions about toxicity and radiotherapy efficacy.

CONCLUSIONS:

For men with high‐risk PCA, RT + H was superior to S + RT, and the result was sensitive to the risk of all‐cause mortality from H. Moreover, trimodality therapy may offer local and distant control benefits that lead to optimal outcomes in a meaningful population of men. Cancer 2012;. © 2011 American Cancer Society.