Surgery associated with increased survival compared to radiation in clinically localized Gleason 9-10 prostate cancer: a SEER analysis.

PURPOSE: Men with Gleason score 9-10 prostate cancer have worse outcomes compared to those with Gleason 8 disease. Upfront treatments remain controversial for these patients. Using the Surveillance, Epidemiology, and End Results (SEER) database, we evaluated the impact of initial treatment with external beam radiation therapy (EBRT), external beam radiation therapy with brachytherapy (EBRT + BT), or surgery on prostate cancer-specific mortality (PCSM) and overall mortality (OM) in Gleason 9-10 disease. METHODS: The SEER database was queried for men diagnosed with biopsy Gleason 9-10 prostate cancer from 2005 to 2014. Gathered data included demographic, pathologic, therapy received, and survival outcomes. Kaplan-Meier survival curves and crude and multivariate analyses were generated for initial therapy with EBRT, EBRT + BT, or surgery. RESULTS: A total of 7877 men were included, 4465 (56.7%) who underwent upfront treatment with EBRT alone, 623 (7.9%) with EBRT + BT, and 2789 (35.4%) with surgery. The 7 year PCSM rates were 29.2, 15.0, and 14.6% for EBRT, EBRT + BT, and surgery respectively (p < 0.001). The 7 year OM rates were 43.8, 27.2, and 20.0% for EBRT, EBRT + BT, and surgery, respectively (p < 0.001).When controlling for age, year of diagnosis, Gleason score, clinical T stage, and PSA level on multivariate analysis, EBRT had greater PCSM and OM than surgery (HR 0.41, 95% CI 0.28-0.61, p < 0.001 and HR 0.44, 95% CI 0.34-0.57, p < 0.001 respectively), but the mortality differences was not statistically significant between EBRT and EBRT + BT. CONCLUSION: Among men with localized Gleason 9-10 disease, surgery was associated with statistically significant improved survival outcomes compared to EBRT alone.