Treatment Patterns and Outcomes in Lymph-Node-Positive (pN1) Prostate Cancer: A National Cancer Database Study

Lymph node involvement after radical prostatectomy (pN1) is associated with worse oncologic outcomes, yet its optimal management remains controversial. We evaluated oncologic outcomes and treatment patterns in pN1 prostate cancer.

We analyzed data from the National Cancer Database (NCDB) on men undergoing radical pN1 between 2010 and 2020. Exclusion criteria included distant metastases and delayed androgen-deprivation therapy (ADT) or adjuvant radiotherapy (aRT) beyond 1 year from surgery. The primary outcome was overall survival (OS). Multinomial logistic regression identified demographic and clinical predictors of treatment selection. Inverse probability of treatment weighting (IPTW) was applied to adjust baseline characteristics and perform weighted survival analysis across treatment groups.

Among 13,454 patients with pN1 disease, 51.2% were managed with observation, 17.8% received ADT alone, 26.9% ADT plus aRT, and 4.1% aRT alone. Median follow-up was 56.3 months (IQR:36-83). ISUP grade 4-5, pT3-4 disease, and increased nodal burden were associated with treatment intensification. Compared to Non-Hispanic Whites, Non-Hispanic Black patients had lower odds of receiving ADT plus aRT (aOR: 0.79, 95% CI, 0.69-0.91, P < .001). ADT alone or aRT alone did not improve OS; ADT combined with aRT was significantly associated with improved OS (HR: 0.78, 95% CI, 0.68-0.89, P < .001).

This national analysis revealed variability in postsurgical management for pN1 disease. Only less than a third of men received aRT, despite this treatment being associated with improved OS. Given the observed variability in treatment use and outcomes, our findings support the value of individualized management strategies and multidisciplinary decision-making.