Radical Prostatectomy vs Active Surveillance: Results of Nearly 3 Decades of Follow-up

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Radical prostatectomy offers longer survival vs watchful waiting, except in men with a high Gleason score or presence of extracapsular extension.
Radical prostatectomy offers longer survival vs watchful waiting, except in men with a high Gleason score or presence of extracapsular extension.

Radical prostatectomy was associated with 2.9 years of gained life vs watchful waiting in patients with clinically detected, localized prostate cancer and a long life expectancy, results from a study published in the New England Journal of Medicine have shown. Nonetheless, both a high Gleason score and the presence of extracapsular extension in the prostatectomy arm associated with a higher risk of death from prostate cancer.

This study sought to provide long-term follow-up to a randomized trial that compared radical prostatectomy to watchful waiting (ie, active surveillance). Researchers in Sweden randomly assigned 695 patients with localized prostate cancer to watchful waiting (348 patients) or radical prostatectomy (347 patients) between October 1989 and February 1999, collecting follow-up data through 2017.

By December 31, 2017, 292 patients (84%) in the watchful-waiting arm and 261 patients (75%) in the radical prostatectomy arm had died. Of the deaths, 110 in the watchful-waiting arm and 71 in the prostatectomy arm were due to prostate cancer, with the relative risk of the prostatectomy arm at 0.55 (95% CI, 0.41-0.74; P < .001) and the absolute difference in risk at 11.7 percentage points (95% CI, 5.2-18.2).

The number needed to treat to prevent 1 death from any cause was 8.4. At 23 years post-radical prostatectomy, the average gain in extra years of life was 2.9.

“Extended follow-up 23 years after the initiation of the study corroborated a substantial reduction in the rate of death after radical prostatectomy. The number needed to treat to prevent one death has continued to decrease,” explained the authors.

Among the cohort of men who underwent radical prostatectomy, lesions with extracapsular extension were associated with 5 times the risk of death vs men with lesions without extracapsular extension. Additionally, in this cohort, a Gleason score higher than 7 was associated with a risk of death 10 times higher than in patients with a Gleason score of 6 or lower.

Reference

Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in prostate cancer - 29-year follow-up. N Engl J Med. 2018;379(24):2319-2329.

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