Prostate Cancer Outcomes Worse with Watchful Waiting

Patients who underwent radical surgery had a decreased risk of cancer-related mortality.
Patients who underwent radical surgery had a decreased risk of cancer-related mortality.

Patients with early prostate cancer (PCa) are substantially less likely die from the disease if they undergo radical prostatectomy (RP) instead of watchful waiting, especially if they are younger than 65 years, a study found.

The finding emerged from the Scandinavian Prostate Cancer Group Study Number 4, in which investigators randomly assigned 695 men with early PCa to undergo RP or watchful waiting. During the study, 200 of 347 men in the RP group and 247 of the 348 men in the watchful-waiting group died.

At 18 years of follow-up, RP was associated with an overall significant 44% decreased risk of death from PCa compared with watchful waiting, Anna Bill-Axelson, MD, PhD, of Uppsala University Hospital in Uppsala, Sweden, and colleagues reported in The New England Journal of Medicine (2014;370:932-942). Men younger than 65 years had a significant 55% risk reduction, where older men had a non-significant 25% decreased risk.

Overall, at 18 years of follow-up men in the RP group had a significant 29% decreased risk of death from any cause, but the decrease was significant only in men younger than 65 years (who had a 50% decreased relative risk). Older men had a non-significant 8% decreased relative risk.

In addition, results showed that the RP group overall had a significant 43% decreased risk of distant metastases, but the decreased risk was greater among men younger than 65 (51% vs. 32%). The decreased risk associated with RP varied by tumor risk. Compared with the watchful-waiting group, RP patients with low- and intermediate-risk tumors had a significant 60% and 51% decreased risk of distant metastases. Patients with high-risk tumors had a non-significant 19% decreased risk.

The RP group had a significant overall 51% decreased risk of receiving androgen-deprivation therapy (ADT), with a large reduction observed in men younger than 65 compared with older men (61% vs. 40%). The risk reduction did not differ by tumor risk.

“The hypothesis-generating subgroup analyses and the large proportion of long-term survivors in the watchful-waiting group who never required palliative treatment provide support for active surveillance as an alternative in adequately selected groups,” the investigators concluded. “However, the overall long-term disease burden is also a reminder that factors other than survival should be considered when counseling men with localized prostate cancer; the risk of metastases and ensuring palliative treatments also affect quality of life.”

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