Radical Prostatectomy Versus Radiotherapy for Prostate Cancer: Stage-, Age-, and Frailty-Specific Cancer-Control Outcomes of 2600 Patients.

Background: Both radical prostatectomy (RP) and radiotherapy (RT) are recommended as standard treatments for prostate cancer. The prospective comparisons available to date provide only limited information.

Methods: We used data from the database of our university cancer center to compare the metastasis-free (MFS), cancer-specific (CSS) and overall survival (OS) of all patients with prostate cancer who underwent either RP or RT in the period 2014-2024. Stage-, age-, and frailty-specific sensitivity analyses were carried out.

Results: Of 2685 patients with prostate cancer, 1999 (74%) underwent RP and 686 (26%) underwent RT. The RP patients were younger (66 vs. 74 years); a higher percentage of the RP patients than of the RT patients had high-risk prostate cancer (60% vs. 43%), stage cT3 (47% vs. 9.6%), and stage cN1 (11 vs. 5.2%), while the RT patients more commonly had ECOG status 1-2 (16% vs. 6.7%; p<0.001 for all comparisons). Univariate analyses of MFS mostly favored RT, while univariate analyses of OS mostly favored RP. These differences, however, were no longer seen after adjustment for patient and tumor characteristics in multivariable Cox regression models, nor were they seen in sensitivity analyses of D'Amico risk groups, age categories, or ECOG status. Lastly, in 2:1 propensity-score-matched analyses, no differences between RP and RT were found in any of the oncological outcome measures (p≥0.15 for MFS, CSS, and OS).

Conclusion: The findings of this real-world study of prostate cancer patients who underwent either RP or RT suggest equally effective cancer control by the two methods when the statistical analysis is adjusted for patient and tumor characteristics. At present, patients with high-risk prostate cancer und unfavorable disease stages more commonly undergo RP.