单纯外照射放疗与单纯近距离放疗治疗预后不良的中危前列腺癌患者的结果。
Outcomes of Patients With Unfavorable Intermediate-Risk Prostate Cancer Treated With External-Beam Radiotherapy Versus Brachytherapy Alone.
机构信息
1Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri.
2Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
出版信息
J Natl Compr Canc Netw. 2022 Feb 22;20(4):343-350.e4. doi: 10.6004/jnccn.2021.7061.
BACKGROUND
The NCCN Guidelines for Prostate Cancer currently recommend several definitive radiotherapy (RT) options for men with unfavorable intermediate-risk (UIR) prostate cancer: external-beam RT (EBRT) plus androgen deprivation therapy (ADT) or EBRT plus brachytherapy boost with or without ADT. However, brachytherapy alone with or without ADT is not well defined and is currently not recommended for UIR prostate cancer. We hypothesized that men treated with brachytherapy with or without ADT have comparable survival rates to men treated with EBRT with or without ADT.
METHODS
A total of 31,783 men diagnosed between 2004 and 2015 with UIR prostate cancer were retrospectively reviewed from the National Cancer Database. Men were stratified into 4 groups: EBRT (n=12,985), EBRT plus ADT (n=12,960), brachytherapy (n=4,535), or brachytherapy plus ADT (n=1,303). Inverse probability of treatment weighting (IPTW) was used to adjust for covariable imbalances, and weight-adjusted multivariable analysis (MVA) using Cox regression modeling was used to compare overall survival (OS) hazard ratios (HRs).
RESULTS
Relative to EBRT alone, the following treatments were associated with improved OS: EBRT plus ADT (HR, 0.92; 95% CI, 0.87-0.97; P=.002), brachytherapy alone (HR, 0.90; 95% CI, 0.83-0.98; P=.01), and brachytherapy plus ADT (HR, 0.78; 95% CI, 0.69-0.88; P=.00006). Brachytherapy correlated with improved OS relative to EBRT in men who were not treated with ADT (HR, 0.92; 95% CI, 0.84-0.99; P=.03) and in those receiving ADT (HR, 0.84; 95% CI, 0.75-0.95; P=.004). At 10-year follow-up, 56% and 63% of men receiving EBRT and brachytherapy, respectively, were alive (P<.0001). IPTW was used to determine the average treatment effect of definitive brachytherapy. Relative to EBRT, definitive brachytherapy correlated with improved OS (HR, 0.90; 95% CI, 0.84-0.97; P=.009) on weight-adjusted MVA.
CONCLUSIONS
Definitive brachytherapy was associated with improved OS compared with EBRT. The addition of ADT to both EBRT and definitive brachytherapy was associated with improved OS. These results suggest that definitive brachytherapy should be considered as an option for men with UIR prostate cancer.
背景
目前，NCCN 前列腺癌指南建议几种有不利中危因素（UIR）的前列腺癌的确定性放射治疗（RT）选择：外照射 RT（EBRT）加雄激素剥夺治疗（ADT）或 EBRT 加近距离放射治疗加量，加或不加 ADT。然而，单独使用近距离放射治疗，无论是否加 ADT，都没有得到很好的定义，目前不推荐用于 UIR 前列腺癌。我们假设接受近距离放射治疗加或不加 ADT 的患者与接受 EBRT 加或不加 ADT 的患者的生存率相当。
方法
从国家癌症数据库中回顾性分析了 2004 年至 2015 年间诊断为 UIR 前列腺癌的 31783 名男性。将患者分为 4 组：EBRT（n=12985）、EBRT 加 ADT（n=12960）、近距离放射治疗（n=4535）或近距离放射治疗加 ADT（n=1303）。使用逆概率治疗加权（IPTW）来调整协变量的不平衡，并使用 Cox 回归模型进行加权多变量分析（MVA）来比较总生存率（OS）的危险比（HR）。
结果
与 EBRT 相比，以下治疗方法与 OS 改善相关：EBRT 加 ADT（HR，0.92；95%CI，0.87-0.97；P=.002）、单独近距离放射治疗（HR，0.90；95%CI，0.83-0.98；P=.01）和近距离放射治疗加 ADT（HR，0.78；95%CI，0.69-0.88；P=.00006）。在未接受 ADT 治疗的男性（HR，0.92；95%CI，0.84-0.99；P=.03）和接受 ADT 治疗的男性（HR，0.84；95%CI，0.75-0.95；P=.004）中，近距离放射治疗与 EBRT 相比与 OS 改善相关。在 10 年随访中，分别接受 EBRT 和近距离放射治疗的男性中有 56%和 63%存活（P<.0001）。使用 IPTW 来确定确定性近距离放射治疗的平均治疗效果。与 EBRT 相比，确定性近距离放射治疗与 OS 改善相关（HR，0.90；95%CI，0.84-0.97；P=.009），这是在加权 MVA 上的结果。
结论
与 EBRT 相比，确定性近距离放射治疗与 OS 改善相关。EBRT 和确定性近距离放射治疗加 ADT 均可改善 OS。这些结果表明，对于 UIR 前列腺癌患者，应考虑确定性近距离放射治疗作为一种选择。
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