Re: Radical Prostatectomy or Watchful Waiting on Early Prostate Cancer

for this article http://dx.doi.org/10.1016/j.juro.2014.05.075 available at http://jurology.com/ Editorial Comment: This study provides updated outcomes from the well-known and publicized Scandinavian randomized trial of radical prostatectomy and watchful waiting with estimates of 15-year survival. The authors demonstrate that previously described improvements in prostate cancer specific survival following radical prostatectomy persist at a median followup of 12.8 years. In addition, prostatectomy decreased the rate of bone metastasis, locally advanced disease and hormonal therapy use. On subset analysis improved survival was noted in men with a prostate specific antigen (PSA) of 10 or less, men with low risk disease and men younger than 65 years. Among older men (greater than 65 years) a reduction in metastasis was observed but overall survival was not improved due to competing risks of mortality. While I suspect that this study will not provide an "aha" moment for those on the United States Preventive Services Task Force (after all, these men were not diagnosed with a screening test and they had more advanced disease at presentation than men in contemporary screening cohorts), it does inform us in many ways. First, the study demonstrates that prostate cancer is not an innocuous disease as it is often now depicted in the lay press and the nonurological literature. Among men in the watchful waiting arm of this study prostate cancer death occurred in 1 of 5, metastasis in 1 of 3 and local progression in 1 of 2, and 2 of 3 required androgen deprivation. If one were to follow current recommendations and check PSA only when men are symptomatic, one could assume that at least 1 in 5 men would die of prostate cancer if left untreated, and 1 in 7 would die if treated. The study also reminds us that prostate cancer mortality is purely a function of lead time. Men with low or high risk prostate cancer have the potential to die of prostate cancer if they live long enough. If one treats a healthy man, he is likely to benefit. If one treats men on the verge of death from other causes, as in the case of PIVOT (Prostate Cancer Intervention versus Observation Trial), then the outcome would be different. In my mind this begs for individualized treatment involving the patient and his desires, not abstinence from care. As our aging population continuously becomes healthier and carries greater longevity, these observations should also remind us that the money we save on avoided PSA tests and biopsies would likely cost us a great deal in managing the inevitable consequences of advanced prostate cancer.