The Best Therapy for Gleason 10s

We recently saw (see this link) that men diagnosed with Gleason score (GS) of 9 or 10 had lower rates of metastases and better prostate-cancer survival if they were treated with a combination of external beam radiation (EBRT) plus a brachytherapy boost to the prostate ("brachy boost therapy" - BBT) than if they were initially treated with EBRT, or if they were initially treated with surgery (RP). The same researchers looked at a subset of patients who were initially diagnosed as GS 10.

There were only 112 patients who were biopsy-determined as GS 10. Of those,

• 26 were initially treated with RP (median age 61)
• 48 were initially treated with EBRT (median age 68)
• 38 were initially treated with BBT (median age 67)

The median follow-up was relatively short:

• 3.9 years for RP
• 4.8 years for EBRT
• 5.7 years for BBT

• Upfront androgen deprivation was given to 98% of EBRT patients vs. 79% of BBT patients
• Post RP radiation was given to 34%
• Pre-RP systemic therapy was given to 35%

By 5 years of follow-up:

• Only 3% of the BBT cohort received systemic salvage therapy vs. 23% of the RP group and 21% of the EBRT group
• Distant-metastasis-free survival (adjusted) was 64% for RP,  62% for EBRT, and 87% for BBT
• Prostate cancer-specific survival (adjusted) was 87% for RP. 75% for EBRT, and 94% for BBT
• Overall survival was not significantly different in the 5-year time frame

While GS 10 is often more aggressive, it is noteworthy that 87% of those receiving BBT had no distant metastases detected within 5 years. Among men who received RP,  57% were upstaged to T3/4 and 41% were downgraded to GS 7-10 by post-prostatectomy pathology. We have no reason to believe those percentages would differ markedly among those who received radiation.

Although the numbers here are small, this is the largest analysis of Gleason 10s broken down by the therapy that they received that we have ever seen. Only a randomized clinical trial can provide a definitive answer. Given the aggressive course of GS 10, patients with this diagnosis are advised to talk to a radiation oncologist who specializes in this therapy.