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Radical prostatectomy or watchful waiting in early prostate cancer.

Anna Bill-Axelson1, Lars Holmberg, Hans Garmo

  • 1From the Departments of Surgical Sciences (A.B.-A., M.H.) and Immunology, Genetics, and Pathology (C.B.), and the Regional Cancer Center Uppsala Örebro (L.H., H.G.), Uppsala University Hospital, Uppsala, the School of Health and Medical Sciences, Örebro University and Department of Urology, Örebro University Hospital, Örebro (S.-O.A., O.A., J.-E.J.), the Department of Urology, Linköping University Hospital, Linköping (A.S.), the Department of Oncology and Pathology, Division of Clinical Cancer Epidemiology (G.S.), and Department of Medical Epidemiology and Biostatistics (J.P., H.-O.A.), Karolinska Institutet, Stockholm, and the Division of Clinical Cancer Epidemiology, Sahlgrenska Academy, Gothenburg (G.S.) - all in Sweden; King's College London, School of Medicine, Division of Cancer Studies, London (L.H., H.G.); Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (J.R.R.), and the Department of Epidemiology, Harvard School of Public Health (J.R.R., H.-O.A.) - all in Boston; and the Department of Urology, Helsinki University Central Hospital (K.T.), and the Department of Pathology, University of Helsinki (S.N.) - both in Helsinki.

The New England Journal of Medicine
|March 7, 2014
PubMed
Summary

Radical prostatectomy significantly reduces prostate cancer mortality, with the number needed to treat to prevent one death decreasing over time. Long-term survivors in the watchful waiting group often avoid palliative treatment.

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Area of Science:

  • Urology
  • Oncology
  • Clinical Trials

Background:

  • Radical prostatectomy is a treatment for localized prostate cancer.
  • Long-term benefits of radical prostatectomy require further investigation.

Purpose of the Study:

  • To evaluate the long-term efficacy of radical prostatectomy versus watchful waiting for early prostate cancer.
  • To assess the impact on overall mortality, prostate cancer-specific mortality, and metastasis risk.

Main Methods:

  • A randomized controlled trial (Scandinavian Prostate Cancer Group Study Number 4) comparing radical prostatectomy to watchful waiting.
  • 695 men with early prostate cancer were assigned to treatment groups between 1989-1999.
  • Follow-up extended through 2012, with primary endpoints including all-cause mortality, prostate cancer death, and metastasis.

Main Results:

  • Over 23.2 years, radical prostatectomy showed a 0.56 relative risk of death from prostate cancer (P=0.001).
  • The number needed to treat to prevent one death was 8.
  • Radical prostatectomy reduced the need for androgen-deprivation therapy and was associated with reduced metastasis risk, particularly in younger and intermediate-risk patients.

Conclusions:

  • Extended follow-up confirms radical prostatectomy substantially reduces mortality.
  • Treatment benefits are most pronounced when tailored by patient age and tumor risk.
  • A significant proportion of patients managed with watchful waiting do not require palliative treatment.