Surveillance and Health Services Research Program, Intramural Research, American Cancer Society, Atlanta, GA (CCL, AJ); Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (PJG, JAE).
J Natl Cancer Inst. 2015 May 9;107(7). doi: 10.1093/jnci/djv119. Print 2015 Jul.
Clinically lymph node-positive (cN+) prostate cancer (PCa) is an often-fatal disease. Its optimal management remains largely undefined given a lack of prospective, randomized data to inform practice. We sought to describe modern practice patterns in the management of cN+ PCa and assess the effect of adding radiation therapy (RT) to androgen deprivation therapy (ADT) on survival using the National Cancer Data Base.
Patients with cN+ PCa and without distant metastases diagnosed between 2004 and 2011 were included. Five-year overall survival for patients diagnosed between 2004 and 2006 and treated with ADT alone or ADT+RT were compared. Propensity score (PS) matching was used to balance baseline characteristics, and Cox multivariate regression analysis was used to estimate hazard ratios (HRs) for all-cause mortality.
Of 3540 total patients, 32.2% were treated with ADT alone and 51.4% received ADT+RT. Compared with ADT alone, patients treated with ADT+RT were younger and more likely to have private insurance, lower comorbidity scores, higher Gleason scores, and lower PSA values. After PS matching, 318 patients remained in each group. Compared with ADT alone, ADT+RT was associated with a 50% decreased risk of five-year all-cause mortality (HR = 0.50, 95% CI = 0.37 to 0.67, two-sided P < .001; crude OS rate: 71.5% vs 53.2%).
Using a large national database, we have identified a statistically significant survival benefit for patients with cN+ PCa treated with ADT+RT. These data, if appropriately validated by randomized trials, suggest that a substantial proportion of such patients at high risk for prostate cancer death may be undertreated, warranting a reevaluation of current practice guidelines.
临床上淋巴结阳性（cN+）前列腺癌（PCa）是一种常致命的疾病。由于缺乏前瞻性、随机数据来指导实践，其最佳治疗方法仍未得到明确界定。我们试图描述 cN+ PCa 管理中的现代实践模式，并使用国家癌症数据库评估添加放射治疗（RT）对雄激素剥夺治疗（ADT）对生存的影响。
纳入 2004 年至 2011 年间诊断为 cN+ PCa 且无远处转移的患者。比较 2004 年至 2006 年间诊断并单独接受 ADT 或 ADT+RT 治疗的患者的 5 年总生存率。使用倾向评分（PS）匹配来平衡基线特征，并使用 Cox 多变量回归分析来估计全因死亡率的危险比（HR）。
在 3540 例患者中，32.2%接受单独 ADT 治疗，51.4%接受 ADT+RT。与单独 ADT 相比，接受 ADT+RT 的患者年龄较小，更可能拥有私人保险，合并症评分较低，Gleason 评分较高，PSA 值较低。在 PS 匹配后，每组仍有 318 例患者。与单独 ADT 相比，ADT+RT 与 5 年全因死亡率降低 50%相关（HR=0.50，95%CI=0.37 至 0.67，双侧 P<0.001；粗 OS 率：71.5%vs53.2%）。
使用大型国家数据库，我们确定了接受 ADT+RT 治疗的 cN+ PCa 患者具有统计学显著的生存获益。如果通过随机试验得到适当验证，这些数据表明，相当一部分处于前列腺癌死亡高风险的此类患者可能治疗不足，需要重新评估当前的实践指南。
