Radical Prostatectomy Versus Radiation Therapy for Locally Advanced and Clinically Nodal Positive Prostate Cancer

Radical prostatectomy (RP) and radiation therapy (RT) are both recommended as standard-of-care for advanced prostate cancer (aPCa). However, data on comparisons for aPCa are scant.

We relied on the University Cancer Center database to investigate outcomes in metastasis-free (MFS), cancer-specific (CSS) and overall survival (OS) of cT3-4 and cN1 RP versus RT-treated patients between 2014 and 2024.

Of 1017 cT3-4 patients, 93% underwent RP, which were significantly younger (67 vs. 75 years) and harbored significantly lower PSA level (9.3 vs. 12.7 ng/ml). Moreover, significant higher rates of ISUP4-5 in RT patients were observed (51% vs. 37%, P = .001). Univariable MFS, CSS and OS outcomes did not differ for cT3-4 patients. In multivariable adjusted MFS, CSS and OS outcomes also no difference between RP vs. RT-treated cT3-4 patients were observed (all P > .05). Of 239 cN1 patients, 87% underwent RP, which were also younger (66 vs. 73 years, P < .001) and with clinically meaningful lower PSA level (15.4 vs. 29.0 ng/ml, P = .09), relative to RT patients. In univariable MFS analyses, RT provided better results, with no differences for CSS and OS. However, after multivariable adjustment MFS, CSS and OS analyses showed no significant differences between RP vs. RT-treated cN1 patients (all P > .05).

Real-world evidence of currently RP vs. RT-treated locally advanced cT3-4 and clinically node-positive prostate cancer patients suggest equally efficient cancer-control outcomes such as MFS, CSS and OS when adjusting for different patient and tumor characteristics and show excellent cancer control rates in this very-high risk cohort.