Men younger than 60 years with localized high-grade prostate cancer are less likely to die from their disease if they undergo radical prostatectomy (RP) instead of radiation therapy (RT), new study findings suggest.

Noting conflicting results from previous studies, Mohummad Minhaj Siddiqui, MD, and colleagues from the University of Maryland, used the SEER (Surveillance, Epidemiology and End Results) database (2004 to 2014) to identify 2228 men younger than 60 years who had biopsy Gleason score 8 to 10 prostate cancer (PCa) with no nodal or distant metastases. The team focused on younger patients with localized high-grade disease because these men have a worse prognosis and lower likelihood of competing causes of death than older patients. Of the 2228 men, 1459 (65.5%) underwent initial RP and 769 (34.5%) initial external beam radiation therapy (EBRT) with or without androgen deprivation therapy (ADT). The EBRT group included 186 patients who also received brachytherapy.

Patients with up-front RP had a significant 63% and 59% reduction in PCa-specific and overall mortality, respectively, compared with initial RT, after controlling for age, biopsy Gleason score, clinical T stage, and PSA, the investigators reported in the Journal of Urology.

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Dr Siddiqui and the team discussed possible advantages of surgery for young men that might explain improved survival. First, pathology evaluation reveals the true extent of cancer, allowing for appropriate adjuvant therapy. Second, RP reduces tumor volume, which may improve response to systemic therapies. Third, detecting biochemical recurrence is easier after RP than RT with discontinued ADT.

Whether EBRT plus brachytherapy improves mortality more than surgery is still unclear, however. Subgroup analyses showed no significant mortality differences between these groups, but analyses may have been underpowered. In addition, 18.2% of men who had RP received adjuvant RT.

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Huang H, Muscatelli S, Naslund M, et al. Evaluation of cancer specific mortality with surgery versus radiation as primary therapy for localized high grade prostate cancer in men younger than 60 years. J Urol. January 2019;201:120-128. DOI:10.1016/j.juro.2018.07.049