Comparative efficacy and safety of treatments for localised prostate cancer: an application of network meta-analysis

<jats:sec><jats:title>Context</jats:title><jats:p>There is ongoing uncertainty about the optimal management of patients with localised prostate cancer.</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>To evaluate the comparative efficacy and safety of different treatments for patients with localised prostate cancer.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Systematic review with Bayesian network meta-analysis to estimate comparative ORs, and a score (0–100%) that, for a given outcome, reflects average rank order of superiority of each treatment compared against all others, using the Surface Under the Cumulative RAnking curve (SUCRA) statistic.</jats:p></jats:sec><jats:sec><jats:title>Data sources</jats:title><jats:p>Electronic searches of MEDLINE without language restriction.</jats:p></jats:sec><jats:sec><jats:title>Study selection</jats:title><jats:p>Randomised trials comparing the efficacy and safety of different primary treatments (48 papers from 21 randomised trials included 7350 men).</jats:p></jats:sec><jats:sec><jats:title>Data extraction</jats:title><jats:p>2 reviewers independently extracted data and assessed risk of bias.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Comparative efficacy and safety evidence was available for prostatectomy, external beam radiotherapy (different types and regimens), observational management and cryotherapy, but not high-intensity focused ultrasound. There was no evidence of superiority for any of the compared treatments in respect of all-cause mortality after 5 years. Cryotherapy was associated with less gastrointestinal and genitourinary toxicity than radiotherapy (SUCRA: 99% and 77% for gastrointestinal and genitourinary toxicity, respectively).</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>The limited available evidence suggests that different treatments may be optimal for different efficacy and safety outcomes. These findings highlight the importance of informed patient choice and shared decision-making about treatment modality and acceptable trade-offs between different outcomes. More trial evidence is required to reduce uncertainty. Network meta-analysis may be useful to optimise the power of evidence synthesis studies once data from new randomised controlled studies in this field are published in the future.</jats:p></jats:sec>