We read the study by Liu et al. (1) with great interest and would like to congratulate the authors for their superb study. The authors compared the oncologic outcomes of radical prostatectomy (RP) versus radiotherapy (RT) in low prostate-specific antigen (PSA) and high Gleason score (GS), prostate cancer (PCa) patients. It deals with a significant clinical issue. As such, there are a few points that we would like to bring up.
As shown in Table 1, RP patients were younger and had an earlier T stage than their RT counterparts. Underlying selection biases in favor of RP patients may exist, such as better performance status and more stable hemoglobin concentration compared to the RT group. However, SEER database does not include the above data, so we could not completely account for selection biases related to physical condition. Fortunately, the database provides reasons why patients did not undergo surgery. One of the reasons is surgery was recommended by the doctor but the patient refused. In the study of Liu et al., the RT group can only include the above-mentioned patients who were appropriate surgical candidates; in this way, selection bias can be reduced to some extent.
Most patients who have undergone RP are cured of PCa. Patients with one or more adverse pathologic features (ie, positive margins, seminal vesicle invasion, extracapsular extension) may benefit from adjuvant RT (aRT)(2). However, Liu et al. did not include the information about aRT provided by the SEER database, which may have an unknown impact on their analysis. Another SEER-based study proved survival results with or without aRT were different among GS 9-10 PCa (3).
Liu et al.’s study included patients with primary PCa but did not exclude multiple primary cancers. However, a prior SEER-based study demonstrated there were at increased risk for cancers of soft tissue including heart, bladder, kidney, and endocrine system among PCa men compared with the general population (4).
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- Liu S, Wang XY, Huang TB, et al. Effect on survival of local treatment in patients with low prostate-specific antigen, high Gleason score prostate cancer: a population-based propensity score-matched analysis. Ann Palliat Med 2020;9:1708-17. [Crossref] [PubMed]
- Thompson IM, Valicenti RK, Albertsen P, et al. Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO Guideline. J Urol 2013;190:441-9. [Crossref] [PubMed]
- Knipper S, Palumbo C, Pecoraro A, et al. Survival outcomes of radical prostatectomy vs. external beam radiation therapy in prostate cancer patients with Gleason Score 9-10 at biopsy: A population-based analysis. Urol Oncol 2020;38:79.e9-79.e14. [Crossref] [PubMed]
- Davis EJ, Beebe-Dimmer JL, Yee CL, et al. Risk of second primary tumors in men diagnosed with prostate cancer: a population-based cohort study. Cancer 2014;120:2735-41. [Crossref] [PubMed]