Reply to comparative risk‐adjusted mortality outcomes after primary surgery, radiotherapy, or androgen‐deprivation therapy for localized prostate cancer
Year: 2011
Type: letter
Abstract: In response to our findings of superior risk-adjusted mortality outcomes for surgery over external-beam radiation therapy,1 Madlung et al raise a series of concerns, although none detract from our findings. There is no reason to suspect that comorbidity would affect cancer-specific mortality per se. The all-cause mortality analysis was, in fact, adjusted for comorbidity, and the competing risks regression analysis also reflects both measured and unmeasured comorbidity. Race is of course associated with disease risk, but there is no suggestion in the published literature that race is an independent predictor of mortality after adjustment for risk. However, based on the question raised, we re-ran the primary analysis including race as an additional covariable. Not surprisingly, race was not found to be a predictor in the model, and the impact of treatment modality on mortality was unchanged. As we acknowledged in the Discussion section of the article, the determination of cause of death based on death certificate codes is not without limitations, but this method almost certainly underestimates the mortality events attributable to radiation therapy. A man who dies of bladder cancer caused by radiation is unlikely to be coded as a prostate cancer mortality case, nor is one who dies of a pulmonary embolus after a hip fracture caused by accelerated osteoporosis from pelvic radiation with androgen ablation. A broader definition than that used by us would assign these deaths as cancer-specific in the radiation arm. In an era of the pervasive use of preoperative imaging, a surprise finding of advanced disease at time of surgical exploration leading to termination of the case is extremely rare, at least in the United States, and the notion that such cases would lead to a “substantial overestimation of the effectiveness of RP” is, frankly, nonsensical. The findings we reported are increasingly echoed by other high-quality cohort studies. However, we reiterate that only well-performed, randomized trials, including both surgical and radiation therapy arms, will be able to determine what constitutes the best standard of care for those with high-risk, nonmetastatic prostate cancer. In the interim, however, we are left with the choice between the careful use of observational data or using no data at all. We prefer the former approach. Matthew R. Cooperberg MD*, Andrew J. Vickers MD , Peter R. Carroll MD, MPH , * Department of Urology, University of California, San Francisco, San Francisco, California, Department of Epidemiology and Biostatistics Memorial-Sloan Kettering Cancer Center New York, New York, Department of Urology, University of California, San Francisco, San Francisco, California.
Source: Cancer
DOI: 10.1002/cncr.25947
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2160667912