Radical Prostatectomy or Watchful Waiting in Early Prostate Cancer

Abstract

BACKGROUND Radical prostatectomy reduces mortality among men with localized prostate cancer; however, important questions regarding long-term benefit remain. METHODS Between 1989 and 1999, we randomly assigned 695 men with early prostate cancer to watchful waiting or radical prostatectomy and followed them through the end of 2012. The primary end points in the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) were death from any cause, death from prostate cancer, and the risk of metastases. Secondary end points included the initiation of androgen-deprivation therapy. RESULTS During 23.2 years of follow-up, 200 of 347 men in the surgery group and 247 of the 348 men in the watchful-waiting group died. Of the deaths, 63 in the surgery group and 99 in the watchful-waiting group were due to prostate cancer; the relative risk was 0.56 (95% confidence interval [CI], 0.41 to 0.77; P = 0.001), and the absolute difference was 11.0 percentage points (95% CI, 4.5 to 17.5). The number needed to treat to prevent one death was 8. One man died after surgery in the radical-prostatectomy group. Androgen-deprivation therapy was used in fewer patients who underwent prostatectomy (a difference of 25.0 percentage points; 95% CI, 17.7 to 32.3). The benefit of surgery with respect to death from prostate cancer was largest in men younger than 65 years of age (relative risk, 0.45) and in those with intermediate-risk prostate cancer (relative risk, 0.38). However, radical pros-tatectomy was associated with a reduced risk of metastases among older men (relative risk, 0.68; P = 0.04). CONCLUSIONS Extended follow-up confirmed a substantial reduction in mortality after radical prostatectomy; the number needed to treat to prevent one death continued to decrease when the treatment was modified according to age at diagnosis and tumor risk. A large proportion of long-term survivors in the watchful-waiting group have not required any palliative treatment. (Funded by the Swedish Cancer Society and others.)

When no treatment is the best treatment: Active surveillance strategies for low risk prostate cancers

“…The Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) randomized 695 patients to radical prostatectomy versus watchful waiting with a median follow up time of 13.4 years [6]. The mean age was 65 years, the mean PSA value was 13 ng/mL and the majority of the participants had locally advanced disease, diagnosed on digital rectal examination and therefore palpable.…”

“…A reduction of 12.7 percentage points for cumulative incidence of death from any cause and 17.7 percentage points for prostate cancer-related cumulative incidence of death confirmed a substantial reduction in mortality after radical prostatectomy. In addition, it was concluded that prostatectomy reduced the risk of metastatic disease and the need for androgen deprivation therapy [6].…”

“…The value of radical prostatectomy and radiotherapy, previously the gold standard, is now increasingly questioned in the setting of low risk cancer as concerns regarding overdiagnosis and overtreatment continue to grow [5]. This is further complicated by the fact that the impact of PSA screening on overall cancer mortality remains unclear [6,7].…”

Radiotherapy for Prostate Cancer: is it ‘what you do’ or ‘the way that you do it’? A UK Perspective on Technique and Quality Assurance

“…In that trial, 695 men were randomised to radical prostatectomy (n = 347) or watchful waiting (n = 348) with a median follow-up of 12 years. Overall, there was a significant disease-specific survival advantage for men treated with surgery, but a more recent analysis has indicated that this benefit was greatest for men either 65 years old or younger or with intermediate disease risk at diagnosis [18]. In the PIVOT trial, radical prostatectomy (n = 367) was compared with watchful waiting (n = 364) with a primary outcome of all-cause mortality and secondary outcomes of prostate specific mortality, metastases and symptoms in a largely screen-detected population.…”

Comparative trial assessing suture techniques and types of urinary catheters in vesicourethral anastomotic tensile strength in a porcine model

“…Radical prostatectomy remains standard of care for organ-confined prostate cancer and provides excellent oncological outcomes (1,2). During radical prostatectomy, the continuity of the lower urinary tract is disrupted to allow for complete en-bloc prostate resection and is later restored by means of vesicourethral anastomosis (VUA).…”