Context: It remains unclear to what extent the therapy of the primary local tumor,
such as radical prostatectomy (RP) and radiation therapy (RT), improves overall survival
in patients with low-volume metastatic hormone-sensitive prostate cancer (mHSPC).
However, data suggest a benefit of these therapies in preventing local events secondary
to local tumor progression. Objective: To evaluate the efficacy of adding local therapy
(RP or RT) to systemic therapies, including androgen deprivation therapy, docetaxel,
and/or androgen receptor axis-targeted agents, in preventing local events in mHSPC
patients compared with systemic therapy alone (ie, without RT of the prostate or RP).
Evidence acquisition: Three databases and meeting abstracts were queried in November
2023 for studies analyzing mHSPC patients treated with local therapy. The primary
outcome of interest was the prevention of overall local events (urinary tract infection,
urinary tract obstruction, and gross hematuria) due to local disease progression.
Subgroup analyses were conducted to assess the differential outcomes according to
the type of local therapy (RP or RT). Evidence synthesis: Overall, six studies, comprising
two randomized controlled trials, were included for a systematic review and meta-analysis.
The overall incidence of local events was significantly lower in the local treatment
plus systemic therapy group than in the systemic therapy only groups (relative risk
[RR]: 0.50, 95% confidence interval [CI]: 0.28-0.88, p = 0.016). RP significantly
reduced the incidence of overall local events (RR: 0.24, 95% CI: 0.11-0.52) and that
of local events requiring surgical intervention (RR: 0.08, 95% CI: 0.03-0.25). Although
there was no statistically significant difference between the RT plus systemic therapy
and systemic therapy only groups in terms of overall local events, the incidence of
local events requiring surgical intervention was significantly lower in the RT plus
systemic therapy group (RR: 0.70, 95% CI: 0.49-0.99); local events requiring surgical
intervention of the upper urinary tract was significantly lower in local treatment
groups (RR: 0.60, 95% CI: 0.37-0.98, p = 0.04). However, a subgroup analysis revealed
that neither RP nor RT significantly impacted the prevention of local events requiring
surgical intervention of the upper urinary tract. Conclusions: In some patients with
mHSPC, RP or RT of primary tumor seems to reduce the incidence of local progression
and events requiring surgical intervention. Identifying which patients are most likely
to benefit from local therapy, and at what time point (eg, after response of metastases),
will be necessary to set up a study assessing the risk, benefits, and alternatives
to therapy of the primary tumor in the mHSPC setting. Patient summary: Our study suggests
that local therapy of the prostate, such as radical prostatectomy or radiotherapy,
in patients with metastatic hormone-sensitive prostate cancer can prevent local events,
such as urinary obstruction and gross hematuria. (c) 2024 The Author(s). Published
by Elsevier B.V. on behalf of European Association of Urology. This is an open access
article under the CC BY license (http://creativecommons. org/licenses/by/4.0/).
