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ASCO PROSTATE: All Therapies for Early Prostate Cancer Don't Seem Equal


KISSIMMEE, Fla., Feb. 26 -- For early prostate cancer, a five-year follow-up revealed that prostatectomy or brachytherapy had a small but statistically significant survival advantage over external-beam radiation in more than 2,300 patients.

KISSIMMEE, Fla., Feb. 26 -- For early prostate cancer, a five-year follow-up revealed that prostatectomy or brachytherapy had a small but statistically significant survival advantage over external-beam radiation in more than 2,300 patients.

All patients were treated at the Cleveland Clinic from 1996 through 2003, said radiation oncologist Jay Ciezki, M.D., who presented results of the observational trial at a prostate cancer symposium here.

Dr. Ciezki and colleagues analyzed five-year overall survival among 2,345 men with low- or intermediate-risk disease. There were 665 treated with brachytherapy, 615 treated with external-beam radiation, and 1,065 treated with radical prostatectomy.

The five-year overall survival was roughly 94% for men who received external beam radiation versus about 97% for those who underwent prostatectomy or brachytherapy.

Factors including in the overall survival analysis were age, socioeconomic status, race, body mass index, coronary artery disease, hypertension, dyslipidemia, initial prostate specific antigen (PSA) level, and PSA at biopsy, biopsy Gleason score, clinical state, use of androgen deprivation therapy, androgen deprivation therapy duration, smoking history (including pack years), and Charlson score, the validated comorbidity index.

The median radiation dose for men who received external-beam radiation was 82.89 Gray and all brachytherapy patients received 144 Gray.

After controlling for confounding factors, four factors, including smoking (P=0.0002), higher Charlson score (P<0.0001), age (P<0.0001), and treatment modality (P=0.0158) were independent predictors of poor survival, Dr. Ciezki said.

He added that deduced from baseline Charlson scores, "brachytherapy patients were about twice as sick as external beam radiation patients and about three times as sick as prostatectomy patients."

Five-year survival for all three treatments was excellent. He said 96% of all patients were alive at five years and 89.9% at eight years.

But, even after controlling for a number of potential confounders, "there was a slight excess mortality among patients who received external beam radiation and we don't really know why," he said.

During a sometimes heated discussion period, several members of the audience pressed Dr. Ciezki to reveal cause specific-mortality, but he declined to do so because he and his colleagues have submitted those data in an abstract to the American Society of Clinical Oncology for presentation in June.

When an audience member stated that the difference in five-year survival probably reflected cardiac mortality related to androgen deprivation therapy, Dr. Ciezki suggested that the explanation might not be that simple.

"You would assume that yes, but really you should not assume anything," he said.

Radiation oncologist Deborah Kuban, M.D., of the University of Texas M.D. Anderson Cancer Center in Houston commented that "it is unlikely that this study will change clinical practice because, basically, all these treatments produce very good results and we are fortunate that we can offer patients three options that are each so successful."

And she pointed out that "even though there may be statistical differences in outcomes, this still is not a randomized trial and without randomization it is difficult to account for all the variables."

Dr. Kuban also raised the possibility that the radiation therapy offered in 1996 to 2003, probably was not as potent as therapy offered today. "There have been a lot of changes over seven years," she said.

Dr. Kuban added, "Right now most of us agree that all three of these modalities are similar in outcome."

At a press briefing, Dr. Ciezki said that when he and his colleagues at the Cleveland Clinic attempted to analyze the differences in mortality they were unable to find any pattern.

His Cleveland Clinic colleague, urologist Eric Klein, M.D., speculated that the excess deaths from external-beam radiation might be related to scatter of the radiation field that affects organs and blood vessels.

Dr. Ciezki and Dr. Klein indicated no conflict of interest disclosures. Dr. Kuban consults or advises Calypso medical Technologies, Inc.; owns stock in Immtech International, Inc. and received research funding from an Oncura-Educational Grant.

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