What is the life expectancy after radical prostatectomy versus radiation therapy with Androgen Deprivation Therapy (ADT) for localized prostate cancer?

Life Expectancy After Radical Prostatectomy Versus Radiation with ADT for Localized Prostate Cancer

Radical prostatectomy offers better long-term survival outcomes compared to radiation therapy with ADT for localized prostate cancer, particularly in high-risk disease where surgery showed significantly lower prostate cancer-specific mortality (9.1% vs 17.5%) compared to observation. 1

Risk Stratification and Treatment Options

Low-Risk Prostate Cancer

• For patients with very low or low-risk disease and life expectancy >10 years:
  • Active surveillance is the preferred management approach 1, 2
  • Radical prostatectomy or radiation therapy alone (without ADT) are options for selected patients 1
  • ADT should NOT be added to radiation therapy for low-risk disease 1

Intermediate-Risk Prostate Cancer

• For patients with intermediate-risk disease:
  • Both radical prostatectomy and radiation therapy with 4-6 months of ADT are standard treatment options 1
  • Favorable intermediate-risk disease can be treated with radiation alone, though evidence is less robust than for combined RT+ADT 1
  • Unfavorable intermediate-risk disease benefits more from combined RT+ADT 1

High-Risk Prostate Cancer

• For patients with high-risk disease:
  • Both radical prostatectomy and radiation therapy with 2-3 years of ADT are standard treatment options 1
  • The SPCG-4 trial showed that at 15 years, radical prostatectomy reduced:
    • All-cause mortality (46.1% vs 52.7%) 1
    • Prostate cancer-specific mortality (14.6% vs 20.7%) 1
  • In high-risk patients, radical prostatectomy showed significantly lower prostate cancer-specific death rates (9.1% vs 17.5%) compared to observation 1

Survival Outcomes by Treatment Modality

Radical Prostatectomy

• Advantages:
  • Better long-term cancer control for high-risk disease 1
  • Avoids long-term ADT and its associated side effects 3
  • Allows for better pathological staging and potential adjuvant therapy decisions 1
  • 5-year biochemical progression-free survival (BPFS): 97% 4
  • 5-year clinical progression-free survival (CPFS): 90% 4
  • 5-year cancer-specific survival (CSS): 95% 4
  • 5-year overall survival (OS): 86% 4

Radiation Therapy with ADT

• Advantages:
  • Avoids surgical complications 2
  • Effective when combined with appropriate duration of ADT 3
  • 5-year BPFS with adjuvant RT+ADT: 91% 4
  • 5-year CPFS with adjuvant RT+ADT: 83% 4
  • 5-year CSS with adjuvant RT+ADT: 95% 4
  • 5-year OS with adjuvant RT+ADT: 88% 4

Treatment-Related Side Effects

Radical Prostatectomy

• Higher rates of:
  • Erectile dysfunction (80% vs 45% with observation) 2
  • Urinary incontinence (49% vs 21% with observation) 2
  • Anastomotic strictures 1

Radiation Therapy with ADT

• Side effects include:
  • Hot flashes, fatigue, metabolic changes from ADT 3
  • Potential cardiovascular harm in patients with significant comorbidities 3
  • Possible increased risk of neurocognitive and psychiatric events 3
  • Irritative urinary symptoms 2

Duration of ADT with Radiation

• Intermediate-risk: 4-6 months of ADT 1, 3
• High-risk: 2-3 years of ADT is standard, though emerging data suggests 18 months may be sufficient for select patients 3
• Unfavorable intermediate-risk disease benefits from ADT even in the dose escalation era 3
• For high-risk patients receiving EBRT and ADT, brachytherapy boost should be offered to eligible patients 1

Key Considerations for Treatment Selection

1. Patient age and life expectancy:

   • Life expectancy <5 years: Consider observation/watchful waiting 1
   • Life expectancy 5-10 years: Consider less aggressive treatment approaches 1
   • Life expectancy >10 years: Consider definitive treatment with either RP or RT+ADT 1

2. Risk group stratification:

   • Very low/low risk: Active surveillance preferred, RP or RT alone if treatment needed 1
   • Intermediate risk: RP or RT+ADT (4-6 months) 1
   • High risk: RP or RT+ADT (2-3 years) 1

3. Comorbidities:

   • Significant cardiovascular disease may increase risks with long-term ADT 3
   • Surgical risks may preclude RP in some patients 1

Conclusion

While both radical prostatectomy and radiation therapy with ADT are effective treatments for localized prostate cancer, the evidence suggests that radical prostatectomy may offer better long-term survival outcomes, particularly for high-risk disease. However, treatment selection should consider risk stratification, life expectancy, and potential side effects of each approach.