고위험도 전립선암 환자의 치료 편집하기 (부분)

== 근거표 ==
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!KQ14
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!Reference
|1. Mishra MV, Scher ED, Andrel J, et al. Adjuvant versus salvage radiation therapy for prostate cancer patients with adverse pathologic features: comparative analysis of longterm outcomes. Am J Clin Oncol 2015;38:55-60[8].
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!Study type
|Compative study
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!Patients
|186 patients treated with postprostatectomy radiation therapy with pT3 tumors, or pT2 with positive surgical margins
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!Purpose of Study
|To compare long-term outcomes of men with adverse pathologic features after adjuvant radiation therapy (ART) versus salvage radiation therapy (SRT) after radical prostatectomy at our institution.
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!Study Results
| Cumulative freedom from biochemical failure (FFBF), freedom from metastatic failure (FFMF), and overall survival rates were estimated utilizing the Kaplan-Meier method. Multivariate analyses were performed to determine independent prognostic factors correlated with study endpoints. Propensity score analyses were performed to adjust for confounding because of nonrandom treatment allocation. RESULTS: A total of 186 patients with adverse pathologic features treated with ART or SRT were identified. The median follow-up time after radical prostatectomy was 103 and 88 months after completion of radiation therapy. The Kaplan-Meier estimates for 10-year FFBF was 73% and 41% after ART and SRT, respectively (log-rank, P=0.0001). Ten-year FFMF was higher for patients who received ART versus SRT (98.6% vs. 80.9%, P=0.0028). On multivariate analyses there was no significant difference with respect to treatment group in terms of FFBF, FFMF, and overall survival after adjusting for propensity score. CONCLUSIONS: Although unadjusted analyses showed improved FFBF with ART, the propensity scoreadjusted analyses demonstrated that long-term outcomes of patients treated with ART  and SRT do not differ significantly. These results, with decreased effect size of ART after adjusting for propensity score, demonstrate the potential impact of confounding on observational research.
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!Level of Study
|3
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!Reference
|2. Gandaglia G, Cozzarini C, Mottrie A, et al. The Role of Radiotherapy After Radical Prostatectomy in Patients with Prostate Cancer. Curr Oncol Rep 2015;17:53[4].
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!Study type
|Review article
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!Patients
|1,005 patients (wait-and-see policy [n=503] or postoperative irradiation [n=502])
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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
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!Study Results
|Bolla et al. evaluated 1005 patients with pT3 or pT2R1 pN0 PCa treated with RP included in the European Organisation for Research and Treatment of Cancer (EORTC) trial 22911. Patients were randomized to wait-and-see vs. immediate irradiation after surgery. The authors demonstrated that at a median follow-up of 127 months, immediate RT significantly improved BCR-free survival and local control rates as compared to initial observation. Additionally, post-operative irradiation improved clinical progression-free survival in men younger than 70 years and in patients with positive margins. However, no benefit from adjuvant RT was found in terms of metastasis-free and cancer-specific survival.
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!Level of Study
|1
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!Reference
|3. Hsu CC, Paciorek AT, Cooperberg MR et al. Postoperative radiation therapy for patients at high-risk of recurrence after radical prostatectomy: does timing matter? BJU Int 2015;116(5):713-20[10].
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!Study type
|Multicenter longitudinal observational study
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!Patients
|6,176 (CaPSURE)
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!Purpose of Study
|To evaluate among radical prostatectomy (RP) patients at high-risk of recurrence whether the timing of postoperative radiation therapy (RT) (adjuvant, early salvage with detectable post-RP prostate-specific antigen [PSA], or ‘late’ salvage with a PSA level of >1.0 ng/mL) is significantly associated with overall survival (OS), prostate-cancer specific survival or metastasis-free survival, in a longitudinal cohort.
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!Study Results
|After a median of 74 months after RP, 65 men had died (with 37 events of PCSMM). Adjuvant and salvage RT patients had comparable high-risk features. Compared with adjuvant, salvage RT (early or late) had an increased association with all-cause mortality (hazard ratio [HR] 2.7, P=0.018) and with PCSMM (HR 4.0, P=0.015). PCSMM-free survival differed by further stratification of timing, with 10-year estimates of 88%, 84%, and 71% for adjuvant, early salvage, and late salvage RT, respectively (P=0.026). For PCSMM-free survival and OS, compared with adjuvant RT, late salvage RT had statistically significantly increased risk; however, early salvage RT did not. This analysis suggests that patients who underwent early salvage RT with PSA levels of <1.0 ng/mL may have comparable metastasis-free survival and OS compared with adjuvant RT; however, late salvage RT with a PSA level of >1.0 ng/mL is associated with worse clinical outcomes.
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!Level of Study
|2
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!Reference
| 4. Chen B-H, Cha T-L, Kao C-C, et al. Results of early or delayed adjuvant radiotherapy for prostate cancer with adverse pathological tumor characteristics: A single-institute experience. Urological Science 2015;26:235-7[12]. 
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!Study type
|Single-center longitudinal observational study
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!Patients
|53
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!Purpose of Study
|We present a retrospective study of adjuvant radiotherapy (ART) in adverse pathological tumor characteristics of PCa, and analyze the optimal time for ART.
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!Study Results
|There was no PCa-specific mortality in the 5-year follow-up. When compared with the delayed ART in men with adverse pathological characteristics of PCa, early ART was associated with the trend to improve the 5-year BCFS (89% vs. 73%; p=0.1) and less salvage hormonal therapy (45% vs. 54%; p=0.29). The delayed ART is associated with the trend of fewer urethral strictures (9% vs. 14%; p=0.32). But, there was no significant difference between both groups.
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!Level of Study
|4
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!Reference
|5. Fossati N, Karnes RJ, Boorjian SA, et al. Long-term Impact of Adjuvant Versus Early Salvage Radiation Therapy in pT3N0 Prostate Cancer Patients Treated with Radical Prostatectomy: Results from a Multi-institutional Series. Eur Urol 2017;71:886-93[11].
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!Study type
|Multicenter longitudinal observational 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
|2
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!Reference
|6. Gandaglia G, Briganti A, Clarke N, et al. Adjuvant and Salvage Radiotherapy after Radical Prostatectomy in Prostate Cancer Patients. Eur Urol 2017;72:689-709[16].
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!Study Results
|Systematic review
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!Patients
|70 studies
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!Purpose of Study
|To analyze the role of postoperative radiotherapy (RT) in patients with aggressive PCa 
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!Study Results
|Three randomized trials demonstrated that immediate RT after RP reduces the risk of recurrence in patients with aggressive PCa. However, immediate postoperative RT is associated with an increased risk of acute and late side effects ranging from 15% to 35% and 2% to 8%, respectively. Retrospective studies support the oncologic efficacy of initial observation followed by salvage RT administered at the first sign of recurrence; however, the impact of this delay on long-term control remains uncertain. Hopefully, ongoing randomized trials will shed light on the role of adjuvant RT versus observation ± salvage RT in individuals with adverse features at RP. Accurate patient selection based on clinical characteristics and molecular profile is crucial. Dose escalation, whole-pelvis RT, novel techniques, and the use of hormonal therapy might improve the outcomes of postoperative RT. Immediate RT reduces the risk of recurrence after RP in patients with aggressive disease. However, this approach is associated with an increase in the incidence of short- and long-term side effects. Observation followed by salvage RT administered at the first sign of recurrence might be associated with durable cancer control, but prospective randomized comparison with adjuvant RT is still awaited. Dose escalation, refinements in the technique, and the concomitant use of hormonal therapies might improve outcomes of patients undergoing postoperative RT.
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!Level of Study
|1
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