The highly regarded Elsevier practiceupdate.com site recently sought expert commentary from UCSF Urology Chair, Peter Carroll, MD, MPH, for elucidation on results from the Scandinavian Prostate Cancer Study, led by Anna Bill-Axelson, M.D., Ph.D. The request was to comment on the New England Journal of Medicine article, "Radical Prostatectomy versus Watchful Waiting in Early Prostate Cancer," The study, which Carroll calls, "required reading for anyone who has an interest in the subject," is significant for several reason, among them, it's median long-term follow-up is 13.4 years.
Says practiceupdate.com's Dr. Alan Partin, “Dr. Carroll was chosen because of his longstanding reputation as a leader in the field of surgical cure for prostate cancer and his ability to thoughtfully describe and summarize important concepts in Urology." Practiceupdate.com is a valued outlet for this information as they provide a wide range of healthcare professionals with expert curated content surrounding the latest research, expert opinions and breaking news.
For the full commentary, abstract and brief summary by Dr. Moshe Ornstein, click here.
Carroll's commentary follows:
The impact of PSA screening and treatment on the natural history of prostate cancer continues to spark intense debate. However, a recent study conducted in Scandinavia provides new information and insight into this issue. Bill-Axelson and colleagues updated the results of the Scandinavian Prostate Cancer Study Group Number 4 (SPCG-4) trial, a randomized trial of radical prostatectomy vs watchful waiting for men with non-metastatic prostate cancer.1 This publication is required reading for anyone who has an interest in the subject. The study has many attributes; the most notable are its careful design and long follow-up: 23.2 years (median 13.4).
Extended follow-up confirmed a substantial reduction in mortality (relative risk [RR] = 0.71), prostate cancer–specific mortality (RR = 0.56), distant metastases (RR = 0.57), and the use of androgen deprivation (RR = 0.49) in those treated with surgery compared with watchful waiting, with no evidence that these benefits diminished over time. Benefits varied by patient age and tumor risk. The effects were more pronounced in men younger than age 65 and those with intermediate-risk cancers.
A few caveats are important when trying to put this information into current perspective. The cancers identified were not a result of widespread screening; men in this study had higher-risk cancers, as reflected in the mean PSA of 13 ng/mL compared with those of contemporary cohorts in the US. In addition, the benefit associated with treatment accrued continually over time. The number needed to treat to prevent 1 death, an often-used assessment of relative benefit, decreased from 20 to 8 in the whole cohort from 10 to 18 years. Among men younger than 65 years, the number needed to treat declined from 8 to 4, underscoring the importance of long-term follow-up when assessing the potential benefits of all prostate cancer screening and treatment trials, given the long lead time associated with this disease.
The benefits observed in those with low-risk disease treated with surgery are not at odds with the practice of active surveillance in those with screening-detected cancers, as such cancers are of lower risk than those identified in these patients. Active surveillance follows patients much more closely and intensely compared with the “watchful waiting” practices used in this study. Lastly, surgery is associated with some adverse effects on quality of life, and this should temper widespread enthusiasm for treatment of all patients.2
1. Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med. 2014;370(10):932-942.
2. Johansson E, Steineck G, Holmberg L, et al. Long-term quality-of-life outcomes after radical prostatectomy or watchful waiting: the Scandinavian Prostate Cancer Group-4 randomised trial. Lancet Oncol. 2011;12(9):891-899.
“Published by permission from PracticeUpdate. Copyright © 2014 Elsevier Inc. All rights reserved”