• competing-risks regression;
  • prostatic neoplasms/mortality;
  • prostatic neoplasms/therapy;
  • radiotherapy/statistics and numerical data;
  • United States/epidemiology

Objectives:  To compare the mortality outcomes of radical prostatectomy and radiotherapy as treatment modalities for patients with localized prostate cancer.

Methods:  Our cohort consisted of 68 665 patients with localized prostate cancer, treated with radical prostatectomy or radiotherapy, between 1992 and 2005. Propensity-score matching was used to minimize potential bias related to treatment assignment. Competing-risks analyses tested the effect of treatment type on cancer-specific mortality, after accounting for other-cause mortality. All analyses were stratified according to prostate cancer risk groups, baseline Charlson Comorbidity Index and age.

Results:  For patients treated with radical prostatectomy versus radiotherapy, the 10-year cancer-specific mortality rates were 1.4 versus 3.9% in low-intermediate risk prostate cancer and 6.8 versus 11.5% in high-risk prostate cancer, respectively. Rates were 2.4 versus 5.9% in patients with Charlson Comorbidity Index of 0, 2.4 versus 5.1% in patients with Charlson Comorbidity Index of 1, and 2.9 versus 5.2% in patients with Charlson Comorbidity Index of ≥2. Rates were 2.1 versus 5.0% in patients aged 65–69 years, 2.8 versus 5.5% in patients aged 70–74 years, and 2.9 versus 7.6% in patients aged 75–80 years (all P < 0.001). At multivariable analyses, radiotherapy was associated with less favorable cancer-specific mortality in all categories (all P < 0.001).

Conclusions:  Patients treated with radical prostatectomy fare substantially better than those treated with radiotherapy. Patients with high-risk prostate cancer benefit the most from radical prostatectomy. Conversely, the lowest benefit was observed in patients with low-intermediate risk prostate cancer and/or multiple comorbidities. An intermediate benefit was observed in the other examined categories.