With a median follow-up of 3.91 years, the 10-year prostate cancer-specific survival rate was 100%. By 7.75 years, 50% of men had received active treatment; however, 55.8% of these men received treatment despite continued favorable PSA and PSA-doubling time. The OS rate at 10 years was 77%.[Level of evidence: 3iiB]
Since the early 1980s, a dramatic increase has occurred in the rates of radical prostatectomy in the United States for men aged 65 to 79 years (5.75-fold rise from 1984 to 1990). Wide geographic variation is seen with these rates. A structured literature review of 144 papers has been done in an attempt to compare the following three primary treatment strategies for clinically localized prostate cancer:
- Radical prostatectomy.
- Definitive radiation therapy.
- Watchful waiting.
The authors concluded that poor reporting and selection factors within all series precluded a valid comparison of efficacy for the three management strategies. In another literature review of a case series of patients with palpable, clinically localized disease, the authors found that 10-year prostate cancer-specific survival rates were best in radical prostatectomy series (about 93%), worst in radiation therapy series (about 75%), and intermediate with deferred treatment (about 85%). Because it is highly unlikely that radiation therapy would worsen disease-specific survival, the most likely explanation is that selection factors affect choice of treatment. Such selection factors make comparisons of therapeutic strategies imprecise. A retrospective analysis of outcomes of men demonstrated a 10-year disease-specific survival rate of 94% for expectant management for Gleason score 2 to 4 tumors and 75% for Gleason score 5 to 7 tumors; this is similar to a previous study using the Surveillance, Epidemiology, and End Results database with survival rates of 93% and 77%, respectively.
Radical prostatectomy has been compared to watchful waiting in men with early-stage disease (i.e., clinical stages T1b, T1c, or T2) in a randomized clinical trial performed in Sweden in the pre-PSA screening era.[37,38] Only about 5% of the men in the trial had been diagnosed by PSA screening. The estimated overall mortality difference after 12 years between the radical prostatectomy and watchful waiting arms of the study was not statistically significant: 32.7% versus 39.8%, P = .09; see Figure 1.[Level of evidence: 1iiA]
Figure 1. Scandinavian Prostate Cancer Group-4 (SPCG-4) study. Trial flow diagram of the 695 men randomly assigned in the SPCG-4 study. RT equals radiation therapy; RP equals radical prostatectomy. Copyright A. Bill-Axelson 2008. Published by Oxford University Press. All rights reserved.
In a post hoc subset analysis, there was a statistically significant difference in overall mortality favoring prostatectomy for men aged 65 years and younger: 21.9% versus 40.2%, P = .004 (relative risk [RR] of death = 0.59; 95% confidence interval [CI], 0.41-0.85). In contrast, for men aged 65 years or older, the overall mortality at 12 years for the prostatectomy and watchful waiting arms was 42% versus 39.3%; P = 0.81 (RR of death = 1.04; 95% CI, 0.77-1.40). Overall prostate cancer-specific mortality in the full trial at 12 years favored prostatectomy: 12.5% versus 17.9%, P = .03; RR = 0.65; 95% CI, 0.45-0.94; see Figure 2.[Level of evidence: 1iiB]
Figure 2. Cumulative incidence with 95% confidence intervals (CIs) at 4, 8, and 12 years of endpoints for all patients. A) Overall mortality: relative risk (RR) equals 0.82; 95% CI, 0.65-1.03; P equals .09. B) Prostate cancer (PC) death: RR equals 0.65; 95% CI, 0.45-0.94; P equals .03. C) Metastases: RR equals 0.65; 95% CI, 0.47-0.88; P equals .006. D) Local progression: RR equals 0.36; 95% CI, 0.27-0.47; P less than .001. E) Hormonal treatment: RR equals 0.54; 95% CI, 0.44 -0.68; P less than .001. F) Other palliative treatment: RR equals 0.63; 95% CI, 0.41-0.97; P equals .04. P values (two-sided) were calculated using Gray's test. Copyright A. Bill-Axelson 2008. Published by Oxford University Press. All rights reserved.