EURURO Vol. 72 No. 3

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absolute difference in prostate-cancer mortality between
radically treated and nonradically treated matched groups,
which translated to circa three-fold higher hazard for the
latter cohort (no differences in other-cause mortality were
seen).
Treating the primary lesion in disseminated disease is
the gold standard in several cancer types such as ovarian
and renal cell Median survival from peritoneal
carcinomatosis from gastrointestinal cancer has increased
from 6 mo to > 2 yr with cytoreductive surgery plus
intraperitoneal chemotherapy . A SEER-Medicare study
of 9011 metastatic colon cancer patients showed that 2-yr
survival increases from 8% in the chemotherapy-only group
to 30% in the chemotherapy-plus–removal of the primary
tumor group .
There also exist data in prostate cancer; disseminated
tumor cells in men with localized prostate cancer before
radical prostatectomy confer a five-fold increased risk of
subsequent metastases, but when detected after surgery
there is no increased risk, suggesting that an intact primary
lesion promotes clinical metastases A subgroup
analysis from SWOG-8894 of 1286 men with metastatic
prostate cancer showed a 23% reduction in mortality in
those who had undergone prior radical prostatectomy
compared with those who had not . Retrospective case
series on men with likely occult metastatic disease (PSA
> 50 or N + disease) have demonstrated a survival advan-
tage for surgery of the primary tumor compared with
systemic therapy alone . A recent SEER report of
mortality outcomes in men with metastatic prostate cancer
and treated with radical therapy demonstrated 5-yr overall
survival and disease-specific survival advantage for patients
who underwent surgery or brachytherapy compared with
the nonradically treated group However, the study had a
short median follow-up (16 mo), no data on many
important predictors, small numbers in the surgery
(n = 245) and brachytherapy (n = 129) arms, no external
beam radiation group, and significant patient–tumor
differences between groups at baseline, and it was not a
true population-based study. Data from the Munich Cancer
Registry of metastatic prostate cancer showed 55% 5-yr
overall survival in the surgical group versus 21% in the
nonsurgical group ; again, these data are limited: small
numbers in the surgical arm (n = 74) compared with the
nonsurgical arms (n = 1464), heterogeneity of nonsurgical
treatments, and no attempt to adjust for patient–tumor
differences between the groups.
[(Fig._2)TD$FIG]
Fig. 2 – Cumulative incidence curves of prostate-cancer and other-cause
mortality for the cohort of (A) radically treated and (B) androgen
deprivation patients with PSA > 50 frequency matched by PSA, clinical
stage, M stage, tumor grade, Charlson comorbidity index, age, and year
of diagnosis (n = 1150). White = alive; light blue = other-cause mortality
in the radical therapy group; dark blue = prostate-cancer mortality in
the radical therapy group; light red = other-cause mortality in the
androgen deprivation group; and dark red = prostate-cancer mortality
in the androgen deprivation group. PSA = prostate-specific antigen.
Table 3 – Mortality figures and crude and multivariable model–adjusted subdistribution hazard ratios for androgen deprivation versus
radical therapy for prostate-cancer and other-cause mortality for the subgroup of frequency-matched PSA > 100 cases ( n = 176)
No. of deaths Crude sHR (95% CI) p value Multivariable model–adjusted
sHR (95% CI)
p value
ADT Radical treatment ADT vs radical treatment ADT vs radical treatment
Prostate-cancer mortality 38/88 (43%) 19/88 (22%) 2.66 (1.54–4.59) <0.001 2.93 (1.57–4.02) < 0.001
Other-cause mortality 4/88 (4.5%) 8/88 (9.1%) 0.51 (0.15–1.67) 0.3 0.45 (0.12–1.17) 0.1
ADT = androgen deprivation therapy; CI = confidence interval; sHR = subdistribution hazard ratio.
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