중간위험도 전립선암 환자의 치료 편집하기 (부분)

== 근거표 ==
{| class="wikitable"
!KQ7
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!Reference
|1. Van der Kwast TH, Bolla M, Van Poppel H, et al. Identification of patients with prostate cancer who benefit from immediate postoperative radiotherapy: EORTC 22911. J Clin Oncol 2007;25:4178-86. 
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!Study type
|Prospective Randomized trial
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!Patients
|1,005
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!Purpose of Study
|To evaluate the effect of radiotherapy after prostatectomy in patients with adverse risk factors
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!Study Results
|Margin status assessed by review pathology was the strongest predictor of prolonged biochemical disease-free survival with immediate postoperative radiotherapy (heterogeneity, P<.01): by year 5, immediate postoperative irradiation could prevent 291 events/1,000 patients with positive margins versus 88 events/1,000 patients with negative margins. The hazard ratio for immediate irradiation was 0.38 (95% CI, 0.26 to 0.54) and 0.88 (95% CI, 0.53 to 1.46) in the groups with positive and negative margins, respectively. We could not identify a significant impact of the positive margin localization.
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!Level of Study
|1
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!Reference
|2. Bolla M, et al. Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911). Lancet 2012;380:2018.
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!Study type
|Prospective Randomized trial
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!Patients
|1,005
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!Purpose of Study
|To report the long-term results of a trial of immediate postoperative irradiation versus a wait-and-see policy in patients with prostate cancer extending beyond the prostate, to confirm whether previously reported progression-free survival was sustained
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!Study Results
|1005 patients were randomly assigned to a wait-and-see policy (n=503) or postoperative irradiation (n=502) and were followed up for a median of 10.6 years (range 2 months to 16.6 years). Postoperative irradiation significantly improved biochemical progressionfree survival compared with the wait-and-see policy (198 [39.4%] of 502 patients in postoperative irradiation group vs 311 [61.8%] of 503 patients in wait-and-see group had biochemical or clinical progression or died; HR 0.49 [95% CI 0.41-0.59]; p<0.0001). Late adverse effects (any type of any grade) were more frequent in the postoperative irradiation group than in the wait-and-see group (10 year cumulative incidence 70.8% [66.6-75.0] vs 59.7% [55.3-64.1]; p=0.001).
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!Level of Study
|1
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!Reference
|3. Wiegel T, et al. Adjuvant Radiotherapy Versus Wait-and-See After Radical Prostatectomy: 10-year Follow-up of the ARO 96-02/AUO AP 09/95 Trial. Eur Urol 2014;66:243.
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!Study type
|Prospective Randomized trial
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!Patients
|388
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!Purpose of Study
|To determine the efficiency of ART after a 10-yr follow-up in the ARO 96-02 study
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!Study Results
|The median follow-up was 111 mo for ART and 113 mo for WS. At 10 yr, PFS was 56% for ART and 35% for WS (p<0.0001). In pT3b and R1 patients, the rates for WS even dropped to 28% and 27%, respectively. Of all 307 ITT2 patients, 15 died from PCa, and 28 died for other or unknown reasons. Neither metastasis-free survival nor overall survival was significantly improved by ART. However, the study was underpowered for these end points. The worst late sequelae in the ART cohort were one grade 3 and three grade 2 cases of bladder toxicity and two grade 2 cases of rectum toxicity. No grade 4 events occurred. 
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!Level of Study
|1
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!Reference
|4. Hwang WL, et al. Comparison Between Adjuvant and Early-Salvage Postprostatectomy Radiotherapy for Prostate Cancer With Adverse Pathological Features. JAMA Oncol 2018;25:e175230.
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!Study type
|Propensity score-matched cohort study
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!Patients
|1,566
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!Purpose of Study
|To compare the clinical outcomes of postoperative ART and ESRT administered to patients with prostatecancer with adverse pathological features.
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!Study Results
|Of 1566 patients, 1195 with prostate-specific antigen levels lower than 0.1 ng/mL received ESRT and 371 patients with prostate-specific antigen levels of 0.1 to 0.5 ng/mL received ART. The median age (interquartile range) was 60 (55-65) years. After propensity score matching, the median (interquartile range) follow-up after surgery was similar between the ESRT and ART groups (73.3 [44.9-106.6] months vs 65.8 [40-107] months; P=.22). Adjuvant RT, compared with ESRT, was associated with higher freedom from biochemical failure (12-year actuarial rates: 69% [95% CI, 60%-76%] vs 43% [95% CI, 35%-51%]; effect size, 26%), freedom from distant metastases (95% [95% CI, 90%-97%] vs 85% [95% CI, 76%-90%]; effect size, 10%), and overall survival (91% [95% CI, 84%-95%] vs 79% [95% CI, 69%-86%]; effect size, 12%). Adjuvant RT, lower Gleason score and T stage, nodal irradiation, and postoperative androgen deprivation therapy were favorable prognostic features on multivariate analysis for biochemical failure. Sensitivity analysis demonstrated that the decreased risk of biochemical failure associated with ART remained significant unless more than 56% of patients in the ART group were cured by surgery alone. This threshold is greater than the estimated 12-year freedom from biochemical failure rate of 33% to 52% after radical prostatectomy alone, as determined by a contemporary dynamic nomogram.
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!Level of Study
|2
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!Reference
|5. Fossati N, et al. Long-term Impact of Adjuvant Versus Early Salvage Radiation Therapy in pT3N0Prostate Cancer Patients Treated with Radical Prostatectomy: Results from a Multiinstitutional Series. Eur Urol 2017;71(6):886-93.
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!Study type
|Multicenter, retrospective study
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!Patients
|510
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!Purpose of Study
|To test the hypothesis that aRT was associated with better cancer control and survival compared with observation followed by esRT
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!Study Results
|Overall, 243 patients (48%) underwent aRT, and 267 (52%) underwent initial observation. Within the latter group, 141 patients experienced PSA relapse and received esRT. Median follow-up after RP was 94 mo (interquartile range [IQR]: 53-126) and 92 mo (IQR: 70-136), respectively (p=0.2). MFS (92% vs 91%; p=0.9) and OS (89% vs 92%; p=0.9) at 8 yr after surgery were not significantly different between the two groups. These results were confirmed in multivariable analysis, in which observation followed by esRT was not associated with a significantly higher risk of distant metastasis (hazard ratio [HR]: 1.35; p=0.4) and overall mortality (HR: 1.39; p=0.4) compared with aRT. Using the nonparametric curve fitting method, a comparable proportion of MFS and OS at 8 yr among groups was observed regardless of pathologic cancer features (p=0.9 and p=0.7, respectively). Limitations consisted of the retrospective nature of the study and the relatively small size of the patient population.
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!Level of Study
|3
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!Reference
|6. Buscariollo DL, et al. Long-term results of adjuvant versus early salvage postprostatectomy radiation: A large single-institutional experience. Pract Radiat Oncol 2017;7(2):e125-e133.
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!Study type
|Retrospective study
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!Patients
|718
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!Purpose of Study
|To evaluate freedom from biochemical failure (FFBF), freedom from androgen deprivation therapy (FFADT), freedom from distant metastases (FFDM), and overall survival (OS) after adjuvant radiationtherapy (ART) versus early salvage radiation therapy (ESRT) in men with prostate cancer and adverse pathologic features (pT3 and/or positive surgical margins).
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!Study Results
|Median follow-up was 7.4 and 8.0 years for patients treated with ART and ESRT, respectively. Ten-year FFBF (69% vs 56%, P=.003) and 10-year FFADT (88% vs 81%, P=.046) rates were higher after ART; however, FFDM and OS did not significantly differ. After PS-matching, ART was associated with improved FFBF (P<.0001), FFADT (P=.0001), and FFDM (P=.02). Findings were confirmed in multivariable analyses in unmatched and PS-matched cohorts. Sensitivity analyses showed that FFBF benefit associated with ART lost statistical significance only after 38% of ART patients were assumed to have been cured by surgery and excluded from the model. This corresponds to the upper bound of patients with adverse pathologic features who did not recur after observation in prior randomized trials.
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!Level of Study
|3
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