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Conventional radical versus focal treatment for localised prostate cancer: a propensity score weighted comparison of 6-year tumour control

Prostate Cancer and Prostatic Diseases volume 24, pages 1120–1128 (2021)Cite this article

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Abstract

Background

For localised prostate cancer, focal therapy offers an organ-sparing alternative to radical treatments (radiotherapy or prostatectomy). Currently, there is no randomised comparative effectiveness data evaluating cancer control of both strategies.

Methods

Following the eligibility criteria PSA < 20 ng/mL, Gleason score ≤ 7 and T-stage ≤ T2c, we included 830 radical (440 radiotherapy, 390 prostatectomy) and 530 focal therapy (cryotherapy, high-intensity focused ultrasound or high-dose-rate brachytherapy) patients treated between 2005 and 2018 from multicentre registries in the Netherlands and the UK. A propensity score weighted (PSW) analysis was performed to compare failure-free survival (FFS), with failure defined as salvage treatment, metastatic disease, systemic treatment (androgen deprivation therapy or chemotherapy), or progression to watchful waiting. The secondary outcome was overall survival (OS). Median (IQR) follow-up in each cohort was 55 (28–83) and 62 (42–83) months, respectively.

Results

At baseline, radical patients had higher PSA (10.3 versus 7.9) and higher-grade disease (31% ISUP 3 versus 11%) compared to focal patients. After PSW, all covariates were balanced (SMD < 0.1). 6-year weighted FFS was higher after radical therapy (80.3%, 95% CI 73.9–87.3) than after focal therapy (72.8%, 95% CI 66.8–79.8) although not statistically significant (p = 0.1). 6-year weighted OS was significantly lower after radical therapy (93.4%, 95% CI 90.1–95.2 versus 97.5%, 95% CI 94–99.9; p = 0.02). When compared in a three-way analysis, focal and LRP patients had a higher risk of treatment failure than EBRT patients (p < 0.001), but EBRT patients had a higher risk of mortality than focal patients (p = 0.008).

Conclusions

Within the limitations of a cohort-based analysis in which residual confounders are likely to exist, we found no clinically relevant difference in cancer control conferred by focal therapy compared to radical therapy at 6 years.

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Fig. 1: Two-way propensity weighted failure-free survival (FFS) and overall survival (OS).
Fig. 2: Three-way propensity weighted failure-free survival (FFS) and overall survival (OS).

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Data availability

De-identified participant data that underlie the results reported in this article are stored in an institutional repository and may be shared upon request to the corresponding author.

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Author information

Author notes

  1. These authors contributed equally: Jochem R. N. van der Voort van Zyp, Matt Winkler, Alison Falconer

Authors and Affiliations

  1. Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK

    Marieke J. van Son, Max Peters, Deepika Reddy, Taimur T. Shah, Feargus Hosking-Jervis, Manit Arya, Hashim U. Ahmed, Matt Winkler & Alison Falconer

  2. Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK

    Marieke J. van Son, Max Peters, Jan J. W. Lagendijk & Jochem R. N. van der Voort van Zyp

  3. Department of Radiotherapy, University Medical Centre Utrecht, Utrecht, The Netherlands

    Marieke J. van Son

  4. Department of Urology, Sunderland Royal Hospital, City Hospital Foundation Trust, Sunderland, UK

    Taimur T. Shah & Stuart McCracken

  5. Division of Clinical Oncology, Department of Radiotherapy, Charing Cross Hospital, Imperial College London Healthcare NHS Trust, London, UK

    Stephen Robinson

  6. Imperial Urology, Imperial College Healthcare NHS Trust, London, UK

    Stephen Mangar, Manit Arya, Hashim U. Ahmed, Matt Winkler & Alison Falconer

  7. Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK

    Tim Dudderidge

  8. Department of Urology, Hampshire Hospitals & Ain Shams University Hospitals, Basingstoke, UK

    Richard G. Hindley & Amr Emara

  9. BMI Mount Alvernia Hospital, Guildford, Surrey, UK

    Raj Nigam

  10. Department of Urology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK

    Raj Persad

  11. Department of Urology, Princes Alexandra Hospital NHS Trust, Harlow, UK

    Jaspal Virdi & Manit Arya

  12. Rivers Hospital, Essex, UK

    Jaspal Virdi & Manit Arya

  13. Springfield Hospital, Chelmsford, UK

    Henry Lewi

  14. Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK

    Caroline Moore, Clement Orczyk & Mark Emberton

  15. Department of Urology, UCLH NHS Foundation Trust, London, UK

    Caroline Moore, Clement Orczyk, Mark Emberton & Manit Arya

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Contributions

M.J.v.S. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M.J.v.S., M.P., D.R., T.T.S., H.U.A. and A.F. Drafting of the manuscript: M.J.v.S. Critical revision of the manuscript for important intellectual content: M.P., D.R., T.T.S., J.J.W.L., S.M., T.D., S.M., R.G.H., A.E., R.N., R.P., J.V., H.L., C.M., C.O., M.E., M.A., H.U.A., J.R.N.v.d.V.v.Z., M.W. and A.F. Statistical analysis: M.J.v.S. and M.P. Obtaining funding: not applicable. Administrative, technical, or material support: S.R., F.H.-J. Supervision: H.U.A., J.R.N.v.d.V.v.Z., M.W. and A.F.

Corresponding author

Correspondence to Marieke J. van Son.

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Conflict of interest

Dr Peters and Dr van der Voort van Zyp received a research grant from the Dutch Cancer Society. Dr Reddy received a research grant from Prostate Cancer UK and received travel grants from Imperial Health Charity and Sonacare. Dr Shah received funding from Prostate Cancer UK and the St Peters Trust and has received funding in the past for conference attendance from Astellas, Ferring and Galil Medical. Professor Moore receives funding from the National Institute for Health Research, The European Association of Urology Research Foundation, MRC, Cancer Research UK, Prostate Cancer UK, Movember and the Cancer Vaccine Institute for clinical prostate cancer research. She has received advisory board fees for Genomic Health. Professor Emberton’s research is supported by core funding from the United Kingdom’s National Institute of Health Research (NIHR) UCLH/UCL Biomedical Research Centre. He was awarded NIHR Senior Investigator in 2015. He receives funding from NIHR-i4i, MRC (UK), Cancer Research UK, Sonacare Inc., Trod Medical, Cancer Vaccine Institute and Sophiris Biocorp for trials in prostate cancer. He is a medical consultant to Sonacare Inc., Sophiris Biocorp, Steba Biotech, Exact Imaging and Profound Medical. Professor Ahmed’s research is supported by core funding from the United Kingdom’s National Institute of Health Research (NIHR) Imperial Biomedical Research Centre. He currently receives funding from the Wellcome Trust, Medical Research Council (UK), Prostate Cancer UK, Cancer Research UK, The BMA Foundation, The Urology Foundation, The Imperial Health Charity, Sonacare Inc., Trod Medical and Sophiris Biocorp for trials and studies in prostate cancer. He was a paid medical consultant for Sophiris Biocorp and is still a paid proctor for HIFU, cryotherapy and Rezum water vapour therapy. Dr Winkler received a travel grant and a loan of device from Zicom Biobot. The remaining authors declare no competing interests.

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van Son, M.J., Peters, M., Reddy, D. et al. Conventional radical versus focal treatment for localised prostate cancer: a propensity score weighted comparison of 6-year tumour control. Prostate Cancer Prostatic Dis 24, 1120–1128 (2021). https://doi.org/10.1038/s41391-021-00369-6

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