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identif ied 13,856 men w ith loca lly or reg iona l ly adva nced prostate ca ncer a nd compa red the outcomes of those who received surger y plus radiation with those whose treatment was radia- tion plus A DT. After 10 years, men who received sur- gery plus radiation — the more aggressive treatment — enjoyed a 15-point survival advantage, 89 percent to 74 percent, com- pared with men who received radiation and ADT. The results, published in the journal Cancer, are consistent with other stud- ies that indicate aggressive treatments, i n c lu d i n g r a d i c a l p r o s t a t e c t o m y, a re i ncrea si n g ly com mon for h i g h- risk patients. "Surger y in this group of men has not been popu la r histor ica l ly ... because s u r ger y i n t h i s set t i n g c a n b e ver y technica lly cha lleng ing a nd is associ- ated with a n increased risk of positive margins, so radiation up front with A DT has traditiona lly been offered to these patients," Dr. Ja ng says. " There's some emerging, preliminary data that a select g roup of men with adva nced prostate cancer can benefit from more aggressive loca l t herapies, wherea s prev iously these men were offered less aggressive approaches. ... [T]he treatment paradigm may be cha ng ing." T w o 2 0 17 s t u d i e s u n d e r s c o r e D r. Ja n g 's poi nt . O ne, publ i s he d i n Prostate Cancer and Prostatic Diseases, fou nd t hat use of ra d ica l prost atec- t o m y t o t r e a t h i g h - r i s k p r o s t a t e c a nc er i nc r e a s e d f r om 2 6 p er c ent in 2004 to 42 percent in 2013. A sec- ond study, in T he Journal of Urology, found that men with loca lly adva nced prostate cancer who under went radica l prostatectomy experienced less overa ll a nd prostate-specif ic mor ta lit y tha n those who received radiation. THE IMPORTANCE OF INFORMED DECISION-MAKING As with any observational study, Dr. Jang a nd Lu-Yao encountered limitations in adjusting for confounding factors, such as age, that may have inf luenced patient outcomes. Had they been able to achieve per fect a djust ment , t hey a g ree t hat the sur viva l dispa rity might have been sma ller tha n 15 percent. However, the greater eff icacy of the more aggressive combination therapy did not surprise the resea rchers. " B ot h ra d ica l pros t at ec t omy a nd ra d iation t herapy [a lone] have been used for curative intent, a nd both a re pret t y strong i n control of d isea se," Lu-Ya o says. "A DT ha s been used ... usua l ly for more palliative intent. ... If you think of radical prostatectomy and radiation therapy, it's two curative-intent approaches together. Kind of theoretically, I would expect radical prostatectomy and radiation therapy to be more effective in controlling disease." The more aggressive therapy, however, is not without risk: In the study, men who underwent surgery and radiation were more likely to experience urinary incon- tinence and erectile dysfunction. That, Lu-Yao says, "speaks to the importance of shared decision-making with patients, which is why it's important to support research to generate data for patients and doctors to make better decisions." Ada m Dicker, MD, Ph D, FA STRO, Senior Vice President and Professor and Chair of Enterprise Radiation Oncology at Jefferson Health in Philadelphia, says the study is valuable because it confirms what many prostate cancer specialists have long suspected about the efficacy of aggressive combination therapy for high-risk patients. "Some people will view this as confir- matory to the way they practice, and for others, this may shift their thinking," says Dr. Dicker, who was not involved with the study. "For ... those of us who are 100 percent focused on prostate cancer and have been doing leading-edge research, it confirms what we knew already, although it's one thing to suspect something and another to have some data." Dr. Jang, Lu-Yao and other prostate cancer researchers eagerly await the results of an ongoing randomized trial by the Scandinavian Prostate Cancer Group comparing surgery plus radiation and radiation plus ADT. In the meantime, Dr. Jang says, either approach can yield long-term survival. Every patient, in col- laboration with his physician, must weigh the risks and benefits of each. n A Disparity Between Guidelines and Clinical Practice A 2018 STUDY of the comparative effectiveness of two forms of combination therapy for high-risk prostate cancer patients found that these men often do not receive guidelines-based treat - ment. Both the United States' National Comprehensive Cancer Network and the European Association of Urology/European Society for Radiotherapy and Oncology recommend com - bination therapy for men with high-risk prostate cancer, but about half of the 13,856 men in the study had received only one treatment. Nearly 20 percent had received no treatment. Study co-author Thomas Jang, MD, MPH, FACS, urologic oncologist at Rutgers Cancer Institute of New Jersey, says some variation in practice is to be expected, which makes the discrepancy unsurprising. Nevertheless, he and his co-investigators want to understand it. "[As far as] how to go about making sure everybody adheres to these guidelines, I think more education can be done, or it could be an access- to-care issue," Dr. Jang says. "It's not really clear from our data what the causes are, and certainly we're going to investi- gate that in a future study." M D N E W S . C O M /// M D N E W S C E N T R A L P E N N S Y LVA N I A ■ 2 019 1 5