Survival Benefit of Radical Prostatectomy in Newly Diagnosed Metastatic Prostate Cancer Varies by PSA Level and Site of Metastasis

In patients with newly diagnosed metastatic prostate cancer (mPCa), the appropriate population for radical prostatectomy (RP) remains unclear. Newly diagnosed mPCa patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database and divided into no local therapy (NLT) and RP groups. Propensity score matching (PSM) was used to balance baseline characteristics. Kaplan-Meier curves were used to estimate cancer-specific survival (CSS). A total of 9,215 patients were included, with 8,844 receiving NLT and 371 undergoing RP. After PSM, 321 patients in each group were included. RP was associated with significantly better CSS (HR = 0.38, 95% CI, 0.27-0.54, p < 0.001). Subgroup analyses showed consistent survival benefit of RP except in patients with M1c disease (HR = 0.55, 95% CI, 0.21-1.46, p = 0.229) or PSA ≥60 ng/ml (HR = 1.19, 95% CI, 0.53-2.86, p = 0.673). An exploratory classification defined low tumor burden as PSA <60 ng/ml and M1a/M1b disease, and high tumor burden as PSA ≥60 ng/ml or M1c. RP significantly improved CSS in the low tumor burden group (HR = 0.30, 95% CI, 0.20-0.46, p < 0.001), but not in the high tumor burden group (HR = 0.98, 95% CI, 0.53-1.84, p = 0.961). In patients with newly diagnosed mPCa, the survival benefit of RP varies with tumor burden.