Whole-pelvic Versus Prostate-only Radiotherapy in Clinically Node-negative High-Risk Localised Prostate Cancer: A Systematic Review and Meta-analysis with Reconstructed Individual-patient Data.

In 30 seconds

This systematic review and meta-analysis pooled five phase III randomised trials (5172 patients) comparing elective whole-pelvic radiotherapy (WPRT) with prostate-only radiotherapy (PORT) for clinically node-negative, high-risk localised prostate cancer, including a reconstructed individual-patient-data analysis. WPRT did not improve overall survival: pooled HR 1.07 (95% CI, 0.94 to 1.21); the reconstructed-IPD HR was 0.98 (0.80 to 1.20). Apparent benefits in progression-related outcomes depended on one PSMA-staged, single-centre trial and were not evident when it was excluded. WPRT modestly increased late grade ≥2 genitourinary and gastrointestinal events.

Key findings

• Across five trials and 5172 patients, WPRT did not improve overall survival (HR, 1.07; 95% CI, 0.94 to 1.21).
• Reconstructed individual-patient data also showed no overall-survival benefit (HR, 0.98; 0.80 to 1.20).
• After excluding one PSMA-staged, single-centre trial, biochemical/progression-free survival and metastasis-free survival estimates were 0.90 (0.77 to 1.06) and 1.00 (0.70 to 1.43), respectively.
• WPRT modestly increased late grade ≥2 genitourinary and gastrointestinal events, without a meaningful excess of severe events.

Why it matters

Elective pelvic irradiation adds treatment exposure and can increase late urinary and gastrointestinal toxicity. This synthesis finds no overall-survival advantage and shows that progression-related signals are sensitive to one trial, helping distinguish a possible subgroup hypothesis from a reproducible benefit across randomised evidence.

What to keep in mind

Certainty was moderate for overall survival and very low for biochemical/progression-free and metastasis-free survival. The apparent progression-related benefit was driven by one single-centre trial.