Abstract
BACKGROUND: Medical comorbidity is a confounding factor in prostate cancer (PCa) treatment selection and mortality. Large-scale comparative evaluation of PCa mortality (PCM) and overall mortality (OM) restricted to men without comorbidity at the time of treatment has not been performed. OBJECTIVE: To evaluate PCM and OM in men with no recorded comorbidity treated with radical prostatectomy (RP), external-beam radiation therapy (EBRT), or brachytherapy (BT). DESIGN, SETTING, AND PARTICIPANTS: Data from 10 361 men with localized PCa treated from 1995 to 2007 at two academic centers in the United States were prospectively obtained at diagnosis and retrospectively reviewed. We identified 6692 men with no recorded comorbidity on a validated comorbidity index. Median follow-up after treatment was 7.2 yr. INTERVENTION: Treatment with RP in 4459 men, EBRT in 1261 men, or BT in 972 men. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Univariate and multivariate Cox proportional hazards regression analysis, including propensity score adjustment, compared PCM and OM for EBRT and BT relative to RP as reference treatment category. PCM was also evaluated by competing risks analysis. RESULTS AND LIMITATIONS: Using Cox analysis, EBRT was associated with an increase in PCM compared with RP (hazard ratio [HR]: 1.66; 95% confidence interval [CI], 1.05-2.63), while there was no statistically significant increase with BT (HR: 1.83; 95% CI, 0.88-3.82). Using competing risks analysis, the benefit of RP remained but was no longer statistically significant for EBRT (HR: 1.55; 95% CI, 0.92-2.60) or BT (HR: 1.66; 95% CI, 0.79-3.46). In comparison with RP, both EBRT (HR: 1.71; 95% CI, 1.40-2.08) and BT (HR: 1.78; 95% CI, 1.37-2.31) were associated with increased OM. CONCLUSIONS: In a large multicenter series of men without recorded comorbidity, both forms of radiation therapy were associated with an increase in OM compared with surgery, but there were no differences in PCM when evaluated by competing risks analysis. These findings may result from an imbalance of confounders or differences in mortality related to primary or salvage therapy.