Curative treatment for men with high-risk prostate cancer (PCa) is associated with decreased cancer-specific mortality and should be considered even when serum PSA levels are higher than 20 ng/mL, researchers concluded.

Treatment of men with high-risk PCa is controversial, they noted in an online report in BJU International, because of a lack of conclusive well-controlled or randomized studies comparing outcomes with palliative treatment, radiotherapy (RT), and radical prostatectomy (RP).

A team led by Sam Ladjevardi, MD, PhD, of University Hospital, Uppsala, Sweden, analyzed data from 11,380 men diagnosed with high-risk PCa who had PSA levels of 20-100 ng/mL and no evidence of distant metastases.

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A total of 7,476 patients received palliative treatment and 3,904 had curative treatment, most commonly RP and external beam RT. The 10-year PCa-specific mortality for patients with a PSA level of 20-50 ng/mL was 36% for patients who received palliative care compared with 13% for those who had curative treatment, according to the investigators. For subjects with PSA levels of 51-100 ng/mL, the 10-year PCa-specific mortality was 55% and 20%, respectively.

Among patients with PSA levels of 20-50 ng/mL at diagnosis, those treated with curative intent had a 77% decreased risk of PCa-related mortality compared with patients who received palliative care, after adjusting for age, comorbidities, disease stage, PSA level, and Gleason score. Among patients with PSA levels of 51-100 ng/mL, patients who had curative treatment had a 78% decreased risk.

The researchers noted that androgen deprivation therapy (ADT) frequently is the first line of treatment for men with PSA levels above 20 ng/mL, but their results show that ADT is not sufficient for these patients. “Either RP or RT in combination with ADT should therefore be considered for men without evidence of distant metastases, even with PSA levels close to 100 ng/mL,” they wrote.

Dr. Ladjevardi’s group said they believe their study is the second largest to analyze cancer-specific mortality among men with high-risk PCa. They pointed out that the risk of selection bias when assessing outcomes after treatment is well known and should not be neglected. Even when adjusting for age, comorbidities, disease stage, PSA level, and Gleason score, residual bias that cannot be accounted for may remain.