Evolving Risk of Urinary Adverse Events Across Localized Prostate Cancer Treatments: A Propensity-weighted Analysis of Surveillance, Epidemiology and End Results-Medicare Data

Prostate cancer treatments can cause long-term urinary adverse events (UAEs), but time-varying risks across treatments remain understudied. Using Surveillance, Epidemiology and End Results-Medicare data, we evaluated men aged ≥66 yr with localized prostate cancer treated with radical prostatectomy (RP), external beam radiotherapy (EBRT), brachytherapy (BT), EBRT + BT, RP + EBRT, or ablation between 2000 and 2017. The primary outcome was any UAE requiring a procedure, with follow-up from treatment initiation and censoring at disease progression. Kaplan-Meier analysis was used to estimate the UAE cumulative incidence and the propensity-weighted restricted mean survival time (RMST) to quantify mean UAE-free survival at 18 yr. The cohort included 166 581 patients: 40% received EBRT, 30% RP, 14% BT + EBRT, 12% BT, 3.1% RP + EBRT, and 1.7% ablation. Combined therapy carried the highest risk, with other modalities showing time-dependent changes. At 18 yr, the UAE risk was highest for RP + EBRT (41%), followed by BT + EBRT (35%), EBRT (29%), RP (23%), and BT (22%). Adjusted RMST to 18 yr was shortest for RP + EBRT (13.1 yr) and longest for BT (15.8 yr) and ablation (15.6 yr). In comparison to RP (15.1 yr), UAE-free survival was 2.0 yr shorter with RP + EBRT (RMST ratio 0.87; p < 0.001) and 0.2 yr shorter with EBRT + BT (RMST ratio 0.99; p < 0.001). The balance between oncologic efficacy and long-term urinary toxicity is key to treatment selection.