Overall Survival After Treatment of Localized Prostate Cancer With Proton Beam Therapy, External-Beam Photon Therapy, or Brachytherapy

Yuan Liu, Sagar A Patel, Ashesh B Jani, Theresa W Gillespie, Pretesh R Patel, Karen D Godette, Bruce W Hershatter, Joseph W Shelton, Mark W McDonald, Yuan Liu, Sagar A Patel, Ashesh B Jani, Theresa W Gillespie, Pretesh R Patel, Karen D Godette, Bruce W Hershatter, Joseph W Shelton, Mark W McDonald

Abstract

Background: There are few comparative outcomes data regarding the therapeutic delivery of proton beam therapy (PBT) versus the more widely used photon-based external-beam radiation (EBRT) and brachytherapy (BT). We evaluated the impact of PBT on overall survival (OS) compared to EBRT or BT on patients with localized prostate cancer.

Patients and methods: The National Cancer Data Base (NCDB) was queried for 2004-2015. Men with clinical stage T1-3, N0, M0 prostate cancer treated with radiation, without surgery or chemotherapy, were included. OS, the primary clinical outcome, was fit by Cox proportional hazard model. Propensity score matching was implemented for covariate balance.

Results: There were 276,880 eligible patients with a median follow-up of 80.9 months. A total of 4900 (1.8%) received PBT, while 158,111 (57.1%) received EBRT and 113,869 (41.1%) BT. Compared to EBRT and BT, PBT patients were younger and were less likely to be in the high-risk group. On multivariable analysis, compared to PBT, men had worse OS after EBRT (adjusted hazard ratio [HR] = 1.72; 95% confidence interval [CI], 1.51-1.96) or BT (adjusted HR = 1.38; 95% CI, 1.21-1.58). After propensity score matching, the OS benefit of PBT remained significant compared to EBRT (HR = 1.64; 95% CI, 1.32-2.04) but not BT (adjusted HR = 1.18; 95% CI, 0.93-1.48). The improvement in OS with PBT was most prominent in men ≤ 65 years old with low-risk disease compared to other subgroups (interaction P < .001).

Conclusion: In this national data set, PBT was associated with a significant OS benefit compared to EBRT, and with outcomes similar to BT. These results remain to be validated by ongoing prospective trials.

Trial registration: ClinicalTrials.gov NCT01617161 NCT03561220.

Keywords: Brachytherapy; Comparative effectiveness; External-beam radiation; Localized prostate cancer; Proton beam radiation.

Conflict of interest statement

Disclosure

The authors have stated that they have no conflict of interest. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The data used in the study are derived from a deidentified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology used, or the conclusions drawn from these data by the investigators.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
Kaplan-Meier Curves With Number at Risk of Overall Survival by 3 Comparison Cohorts. (A) Original Study Population. (B) Propensity Score–matched Population
Figure 2
Figure 2
Summary of Covariate Balance Improvement Measured by Absolute Standardized Difference before and after Generalized Propensity Score Matching
Figure 3
Figure 3
Summary of Subgroup Analysis by Multivariable Cox Proportional Hazard Model With Forest Plots. (A) Stratified by Age Group. (B) Stratified by National Comprehensive Cancer Network (NCCN) Risk Group. (C) Stratified by Combinations of (A) and (B) Strata

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