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Purpose  The purpose is to evaluate the patterns of care and comparative effectiveness for cause-specific and overall survival of definitive local treatments versus conservatively managed men with a primary or secondary Gleason pattern of 5.  Methods and materials  Patients diagnosed from 2004 to 2012 with a primary or secondary Gleason pattern of 5 N0M0 prostate cancer were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier and Cox regression analyses were used to estimate the survival.  Results  We identified 20,560 men. Median age and follow-up were 68 years and 4.33 years, respectively. At eight years, cause-specific survival (CSS) was 86.6% and 57.4% of those receiving and not receiving definitive local treatments, respectively. For CSS multivariate analysis, the following were significant: age, race, insurance status, total Gleason Score, T-stage, and type or omission of definitive local treatments. Compared to prostatectomy alone, men not undergoing definitive local treatments had the highest risk of death (HR: 6.07; 95% CI: 5.19-7.10). Those undergoing external beam radiotherapy alone (HR: 2.11; 95% CI: 1.80-2.48) were also at elevated risk of death. The number needed to treat (NNT) to prevent a prostate cancer death at eight years was three persons.  Conclusions  Death from prostate cancer with a primary or secondary Gleason pattern of 5 histology without definitive local treatment is high. In this hypothesis-generating study, we found that men with a limited life expectancy (less than eight years) and non-metastatic Gleason pattern of 5 disease may benefit from definitive local treatments. Given the high mortality in men with a Gleason pattern of 5, combined modality local therapies and consideration of chemotherapies may be warranted.

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Risk of Death from Prostate Cancer with and without Definitive Local Therapy when Gleason Pattern 5 is Present: A Surveillance, Epidemiology, and End Results Analysis