EURURO Vol. 71 No. 4

E115 692

Letter to the Editor
Reply to [3_TD$DIFF]Glen [4_TD$DIFF]Denmer [5_TD$DIFF]Santok and [6_TD$DIFF]Koon [7_TD$DIFF]Ho [8_TD$DIFF]Rha’s
Letter to the Editor re: Pa¨r Stattin, Fredrik Sandin,
Frederik Birkebæk Thomsen, et al. Association of Radical
Local Treatment with Mortality[9_TD$DIFF] in Men with Very
High-risk Prostate Cancer: A Semiecologic, Nationwide,
Population-based Study. Eur Urol. In press[10_TD$DIFF].
We thank Santok and Rha for their kind interest in our
paper on the effect of radical local treatment in men with
very high-risk or locally advanced prostate cancer without
evidence of distant metastasis They suggest that the
extent of pelvic lymph node dissection (PLND) might have
contributed to our finding that radical local treatment was
associated with a lower mortality.
PCBase does not include information on the extent of the
PLND, but one would expect a higher proportion of positive
findings (N1) on PLND in units where a more extended
PLND was routinely carried out. in our article
indirectly shows the proportion of N1 on PLND , because
a PLND was required for categorising the stage as N0 or N1.
The proportion of N1 on PLND in men with very high-risk
disease was lower in the units with high use of radical
therapy (13%) than in the units with lowest use of radical
therapy (33%; ). This does not support the hypothesis
that the extent of PLND was important for reducing prostate
cancer death, but rather suggests a selection of men with
more favourable cancer for radical local treatment in the
more treatment-active units.
Our study is neither suitable for evaluating the potential
benefit of an extensive PLND, nor for comparing the
outcomes of radical prostatectomy and radiotherapy. It is
worth noticing that more men in our study had PLND as a
staging procedure before radiotherapy than as part of a
radical prostatectomy. Surgical staging before radiothera-
py was common practice in Sweden during the first half of
the study period. Men with lymph node metastases on
PLND back then were usually managed with androgen
deprivation treatment only. Moreover, 80% of men who
had radical local treatment had radiotherapy; only 20% had
a radical prostatectomy and of these men only 50% also
had PLND.
Even though our semiecologic study corroborates the
results from previous conventional observational analytical
studies comparing results for men who did or did not
receive radical local treatment for advanced prostate
cancer, observational studies cannot entirely overcome
bias from the selection of men with less advanced and
aggressive cancer for radical local treatment even within
defined risk categories. Randomised clinical trials are
needed if a beneficial effect of radical local treatment of
very high-risk prostate cancer is to be proven. It is essential
that quality-of-life aspects are also incorporated in future
studies.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
.
ava ilable at
journal homepage:
Table 1 – Proportion (%) of men that had pelvic lymph node
dissection (PLND) with (N1) and without (N0) detection of lymph
node metastasis in units according to tertiles of use of radical local
treatment
Radical treatment in experimental
unit (%) for very high-risk Pca
0–33 34–66 67–100
N stage defined by PLND
N0 8 24 26
N1 4 8 4
Nx, missing 89 68 47
N1% (N1/N1 + N0) 33 25 13
Pca = prostate cancer.
DOIs of original articles: , .
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.