Ten-year mortality, disease progression and treatment-related side-effects in men with localised prostate cancer from the ProtecT randomised controlled trial according to treatment received

David E Neal, Chris Metcalfe, Jenny L Donovan, J. Athene Lane, Michael J Davis, Grace J Young, Susan J Dutton, Eleanor I Walsh, Richard M Martin, Tim J. Peters, Emma L Turner, Malcolm Mason, Prasad Bollina, James Catto, Alan Doherty, David Gillatt, Vincent Gnanapragasam, Peter Holding, Owen Hughes, Roger KockelberghHoward Kynaston, Jon Oxley, Alan Paul, Edgar Paez, Derek J. Rosario, Edward Rowe, John Staffurth, Doug G Altman, Freddie C. Hamdy

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Abstract

Background
The ProtecT trial reported intention-to-treat analysis of men with localised prostate cancer randomly allocated to active monitoring (AM), radical prostatectomy, and external beam radiotherapy.

Objective
To report outcomes according to treatment received in men in randomised and treatment choice cohorts.

Design, setting, and participants
This study focuses on secondary care. Men with clinically localised prostate cancer at one of nine UK centres were invited to participate in the treatment trial comparing AM, radical prostatectomy, and radiotherapy.

Intervention
Two cohorts included 1643 men who agreed to be randomised and 997 who declined randomisation and chose treatment.

Outcome measurements and statistical analysis
Analysis was carried out to assess mortality, metastasis and progression and health-related quality of life impacts on urinary, bowel, and sexual function using patient-reported outcome measures. Analysis was based on comparisons between groups defined by treatment received for both randomised and treatment choice cohorts in turn, with pooled estimates of intervention effect obtained using meta-analysis. Differences were estimated with adjustment for known prognostic factors using propensity scores.

Results and limitations
According to treatment received, more men receiving AM died of PCa (AM 1.85%, surgery 0.67%, radiotherapy 0.73%), whilst this difference remained consistent with chance in the randomised cohort (p = 0.08); stronger evidence was found in the exploratory analyses (randomised plus choice cohort) when AM was compared with the combined radical treatment group (p = 0.003). There was also strong evidence that metastasis (AM 5.6%, surgery 2.4%, radiotherapy 2.7%) and disease progression (AM 20.35%, surgery 5.87%, radiotherapy 6.62%) were more common in the AM group. Compared with AM, there were higher risks of sexual dysfunction (95% at 6 mo) and urinary incontinence (55% at 6 mo) after surgery, and of sexual dysfunction (88% at 6 mo) and bowel dysfunction (5% at 6 mo) after radiotherapy. The key limitations are the potential for bias when comparing groups defined by treatment received and changes in the protocol for AM during the lengthy follow-up required in trials of screen-detected PCa.

Conclusions
Analyses according to treatment received showed increased rates of disease-related events and lower rates of patient-reported harms in men managed by AM compared with men managed by radical treatment, and stronger evidence of greater PCa mortality in the AM group.
Original languageEnglish
Number of pages11
JournalEuropean Urology
Early online date24 Nov 2019
DOIs
Publication statusE-pub ahead of print - 24 Nov 2019

Structured keywords

  • BTC (Bristol Trials Centre)
  • BRTC

Keywords

  • Prostate cancer
  • Disease progression
  • ProtecT trial
  • Active monitoring
  • Radical prostatectomy
  • Radiotherapy
  • Metastasis

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