Long-term outcomes of radical prostatectomy versus radiation therapy for high- and very high-risk localized prostate cancer: an IPTW analysis from a multicenter Asian database

Abstract Background While oncological outcomes of radical prostatectomy (RP) and radiation therapy (RT) for localized prostate cancer are well-evaluated, data focusing on Asian populations remain limited. This study aimed to compare the outcomes of RP versus RT in Asian patients with NCCN high-risk and very high-risk localized prostate cancer. Methods We retrospectively analyzed 1,641 patients with high-risk or very high-risk disease treated between January 2005 and September 2021 from the Chang Gung Research Database (CGRD). Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline confounders—including age, prostate-specific antigen, clinical T stage, Gleason score/Grade Group, and Charlson Comorbidity Index—effectively minimizing significant selection bias. Overall survival (OS) and cancer-specific survival (CSS) were evaluated. Additionally, a competing-risk framework was applied to analyze cancer-specific mortality (CSM). Results After IPTW adjustment, RP was associated with superior OS and CSS compared to RT. In the high-risk cohort, the adjusted hazard ratios (HR) for RT versus RP were 1.81 (95% CI: 1.00–3.33, p =0.038) for OS and 2.67 (95% CI: 1.04–6.81, p =0.015) for CSS. Similarly, for very high-risk patients, the adjusted HRs for RT versus RP were 2.24 (95% CI: 1.49–3.36, p < 0.001) for OS and 2.82 (95% CI: 1.67–4.77, p < 0.001) for CSS. Conclusions This real-world study demonstrates that RP is associated with improved OS and CSS compared to RT for Asian patients with high-risk and very high-risk localized prostate cancer. Validated through rigorous IPTW adjustment, these findings provide valuable clinical evidence to support personalized treatment decision-making, though further prospective randomized trials are warranted to establish causality.