Annals of Surgical Oncology

, Volume 21, Issue 12, pp 4026–4033 | Cite as

A Competing Risk Analysis of Cancer-Specific Mortality of Initial Treatment with Radical Prostatectomy versus Radiation Therapy in Clinically Localized High-Risk Prostate Cancer

  • Joo Yong Lee
  • Kang Su Cho
  • Jong Kyou Kwon
  • Seong Uk Jeh
  • Ho Won Kang
  • Richilda Red Diaz
  • Won Sik Ham
  • Woong Sub Koom
  • Ki Chang Keum
  • Young Deuk ChoiEmail author
Urologic Oncology



There is no consensus on the optimal treatment for localized high-risk prostate cancer (PC), and much debate exists regarding the ideal treatment approach. For these reasons, we evaluated the competing risks of PC-specific mortality after initial therapy with radical prostatectomy (RP) versus radiotherapy (RT) in men with clinically localized high-risk PC.


We reviewed patients treated with RP and RT combined with androgen-deprivation therapy between 1990 and 2009. High-risk PC is defined as clinical stage ≥T3a, serum prostate-specific antigen (PSA) >20 ng/mL, or a biopsy Gleason sum of 8–10 according to National Comprehensive Cancer Network guidelines. Competing risk analysis was conducted to assess the association of RP (n = 251) or RT (n = 125) with cancer-specific mortality (CSM). Thereafter, secondary analysis with propensity score matching was conducted to further elucidate patient characteristics, with optimal matching of 0.25 times the standard deviation of propensity scores.


With an overall median follow-up of 76 months, 35 (9.3 %) men with high-risk PC died due to PC (23 in the RT group and 12 in the RP group). The 5-year estimates of cancer-specific survival rate for men treated with RP and RT were 96.5 % (95 % confidence interval [CI] 94.2–98.9) and 88.3 % (95 % CI 82.8–94.3), respectively. Cumulative incidence estimates for CSM were statistically increased amongst men treated with RT (p = 0.002). Propensity score matching extracted 168 men with high-risk PC from the total patient cohort. Cumulative incidence estimates for CSM were statistically different amongst men treated with RT (p < 0.001).


Initial treatment with RP versus RT was associated with a decreased risk of CSM in men with clinically localized high-risk PC.


Prostate Cancer Propensity Score Radical Prostatectomy National Comprehensive Cancer Network National Comprehensive Cancer Network 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was supported by a grant from the Korean Foundation for Cancer Research (CB-2011-04-02), Republic of Korea.


Joo Yong Lee, Kang Su Cho, Jong Kyou Kwon, Seong Uk Jeh, Ho Won Kang, Richilda Red Diaz, Won Sik Ham, Woong Sub Koom, Ki Chang Keum, and Young Deuk Choi do not have any conflicts of interest.


  1. 1.
    Abdollah F, Suardi N, Cozzarini C, et al. Selecting the optimal candidate for adjuvant radiotherapy after radical prostatectomy for prostate cancer: a long-term survival analysis. Eur Urol. 2013;63:998–1008.PubMedCrossRefGoogle Scholar
  2. 2.
    Bastian PJ, Boorjian SA, Bossi A, et al. High-risk prostate cancer: from definition to contemporary management. Eur Urol. 2012;61:1096–106.PubMedCrossRefGoogle Scholar
  3. 3.
    Heidenreich A, Bastian PJ, Bellmunt J, et al. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent—update 2013. Eur Urol. 2014;65:124–37.PubMedCrossRefGoogle Scholar
  4. 4.
    Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. 2007;177:2106–31.PubMedCrossRefGoogle Scholar
  5. 5.
    Mohler JL, Armstrong AJ, Bahnson RR, et al. Prostate cancer, version 3.2012: featured updates to the NCCN guidelines. J Natl Compr Canc Netw. 2012;10:1081–7.PubMedGoogle Scholar
  6. 6.
    Van Poppel H, Joniau S. An analysis of radical prostatectomy in advanced stage and high-grade prostate cancer. Eur Urol. 2008;53:253–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Hoffman RM, Koyama T, Fan KH, et al. Mortality after radical prostatectomy or external beam radiotherapy for localized prostate cancer. J Natl Cancer Inst. 2013;105:711–8.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Zelefsky MJ, Eastham JA, Cronin AM, et al. Metastasis after radical prostatectomy or external beam radiotherapy for patients with clinically localized prostate cancer: a comparison of clinical cohorts adjusted for case mix. J Clin Oncol. 2010;28:1508–13.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Gaynor JJ, Feuer EJ, Tan CC, et al. On the use of cause-specific failure and conditional failure probabilities: examples from clinical oncology data. J Am Stat Assoc. 1993;88:400–9.CrossRefGoogle Scholar
  10. 10.
    Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc. 1999;94:496–509.CrossRefGoogle Scholar
  11. 11.
    Rubin DB, Thomas N. Matching using estimated propensity scores: relating theory to practice. Biometrics. 1996;52:249–64.PubMedCrossRefGoogle Scholar
  12. 12.
    Rubin DB. On principles for modeling propensity scores in medical research. Pharmacoepidemiol Drug Saf. 2004;13:855–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225–49.PubMedCrossRefGoogle Scholar
  14. 14.
    Goldberg H, Baniel J, Yossepowitch O. Defining high-risk prostate cancer. Curr Opin Urol. 2013;23(4):337–41.PubMedCrossRefGoogle Scholar
  15. 15.
    Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P. Estimates of the cancer incidence and mortality in Europe in 2006. Ann Oncol. 2007;18:581–92.PubMedCrossRefGoogle Scholar
  16. 16.
    D’Amico AV, Moul J, Carroll PR, Sun L, Lubeck D, Chen MH. Cancer-specific mortality after surgery or radiation for patients with clinically localized prostate cancer managed during the prostate-specific antigen era. J Clin Oncol. 2003;21:2163–72.PubMedCrossRefGoogle Scholar
  17. 17.
    Grossfeld GD, Latini DM, Lubeck DP, Mehta SS, Carroll PR. Predicting recurrence after radical prostatectomy for patients with high risk prostate cancer. J Urol. 2003;169:157–63.PubMedCrossRefGoogle Scholar
  18. 18.
    Heidenreich A, Aus G, Bolla M, Joniau S, Matveev VB, Schmid HP, et al. EAU guidelines on prostate cancer. Eur Urol. 2008;53:68–80.PubMedCrossRefGoogle Scholar
  19. 19.
    Sundi D, Jeong BC, Lee SB, Han M. Optimizing the management of high-risk, localized prostate cancer. Korean J Urol. 2012;53:815–20.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Meng MV, Elkin EP, Latini DM, Duchane J, Carroll PR. Treatment of patients with high risk localized prostate cancer: results from cancer of the prostate strategic urological research endeavor (CaPSURE). J Urol. 2005;173:1557–61.PubMedCrossRefGoogle Scholar
  21. 21.
    Joniau S, Tosco L, Briganti A, et al. Results of surgery for high-risk prostate cancer. Curr Opin Urol. 2013;23(4):342–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Qin X, Ye D. Re: Jutta Engel, Patrick J. Bastian, Helmut Baur, et al. Survival benefit of radical prostatectomy in lymph node-positive patients with prostate cancer. Eur Urol. 2010;57:754–61. Eur Urol. 2010;58(4):e43; author reply e44.Google Scholar
  23. 23.
    Qin XJ, Ma CG, Ye DW, et al. Tumor cytoreduction results in better response to androgen ablation: a preliminary report of palliative transurethral resection of the prostate in metastatic hormone sensitive prostate cancer. Urol Oncol. 2012;30:145–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Critz FA, Williams WH, Benton JB, Levinson AK, Holladay CT, Holladay DA. Prostate specific antigen bounce after radioactive seed implantation followed by external beam radiation for prostate cancer. J Urol. 2000;163:1085–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Thompson IM Jr, Tangen CM, Paradelo J, et al. Adjuvant radiotherapy for pathologically advanced prostate cancer: a randomized clinical trial. JAMA. 2006;296:2329–35.PubMedCrossRefGoogle Scholar
  26. 26.
    Wiegel T, Bottke D, Steiner U, et al. Phase III postoperative adjuvant radiotherapy after radical prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with postoperative undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95. J Clin Oncol. 2009;27:2924–30.PubMedCrossRefGoogle Scholar
  27. 27.
    Bolla M, van Poppel H, Tombal B, et al. Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911). Lancet. 2012;380(9858):2018–27.PubMedCrossRefGoogle Scholar
  28. 28.
    Cooperberg MR, Vickers AJ, Broering JM, Carroll PR. Comparative risk-adjusted mortality outcomes after primary surgery, radiotherapy, or androgen-deprivation therapy for localized prostate cancer. Cancer. 2010;116:5226–34.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Boorjian SA, Karnes RJ, Viterbo R, et al. Long-term survival after radical prostatectomy versus external-beam radiotherapy for patients with high-risk prostate cancer. Cancer. 2011;117:2883–91.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Johnstone PA, Ward KC, Goodman M, Assikis V, Petros JA. Radical prostatectomy for clinical T4 prostate cancer. Cancer. 2006;106:2603–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Westover K, Chen MH, Moul J, et al. Radical prostatectomy vs radiation therapy and androgen-suppression therapy in high-risk prostate cancer. BJU Int. 2012;110:1116–21.PubMedCrossRefGoogle Scholar
  32. 32.
    Peeters ST, Heemsbergen WD, van Putten WL, et al. Acute and late complications after radiotherapy for prostate cancer: results of a multicenter randomized trial comparing 68 Gy to 78 Gy. Int J Radiat Oncol Biol Phys. 2005;61:1019–34.PubMedCrossRefGoogle Scholar
  33. 33.
    Saigal CS, Gore JL, Krupski TL, Hanley J, Schonlau M, Litwin MS. Androgen deprivation therapy increases cardiovascular morbidity in men with prostate cancer. Cancer. 2007;110:1493–500.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Joo Yong Lee
    • 1
  • Kang Su Cho
    • 2
  • Jong Kyou Kwon
    • 1
  • Seong Uk Jeh
    • 1
  • Ho Won Kang
    • 1
  • Richilda Red Diaz
    • 1
  • Won Sik Ham
    • 1
  • Woong Sub Koom
    • 3
  • Ki Chang Keum
    • 3
  • Young Deuk Choi
    • 1
    • 4
    Email author
  1. 1.Department of Urology, Severance Hospital, Urological Science InstituteYonsei University College of MedicineSeoulKorea
  2. 2.Department of Urology, Gangnam Severance Hospital, Urological Science InstituteYonsei University College of MedicineSeoulKorea
  3. 3.Department of Radiation Oncology, Severance HospitalYonsei University College of MedicineSeoulKorea
  4. 4.Robot and Minimal Invasive Surgery Center, Severance HospitalYonsei University College of MedicineSeoulKorea

Personalised recommendations