RP edges observation in young men with prostate cancer

Radical prostatectomy is associated with a substantial long-term reduction in mortality in men with localized cancer, especially in younger patients, according to newly published data from one of the few randomized trials to directly address the surgery-versus-surveillance issue.

The article, by researchers from Uppsala University Hospital, Sweden, Harvard School of Public Health, Boston, and colleagues, appears in this week’s New England Journal of Medicine (2014; 370:932-42).

While the benefit on mortality appears to be limited to men under age 65 years, surgery did reduce the risk of metastases and need for additional treatment in older men. The study’s release lit up Twitter, drawing wide-ranging commentary from urologists in the U.S. and abroad.

The researchers used data from the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4), which randomized 695 men with early prostate cancer to treatment with surgery or watchful waiting with no initial treatment, with follow-up for up to 24 years. Over the course of the study, 200 of 347 men in the surgery group and 247 of the 348 men in the watchful waiting group died. Of the deaths, 63 in the surgery group and 99 in the watchful waiting group were due to prostate cancer (relative risk: 0.56; 95% confidence interval: 0.41-0.77; p=.001).

The number needed to treat to prevent one death at 18 years of follow-up was eight.

Continue to next page for comments and reactions to the study.

“The latest results from the SPCG-4 trial indicate that surgery can not only improve survival, especially in men diagnosed at a younger age or with intermediate-risk disease, but also that surgery can reduce the burden of disease in terms of development of metastases and the need for palliative treatment,” said co-author Jennifer Rider, ScD, MPH, of Harvard School of Public Health and Brigham and Women’s Hospital. “However, a large proportion of men in the trial still alive at 18 years did not require initial surgery or any subsequent therapy, pointing to the potential benefits of active surveillance strategies to limit overtreatment.”

James McKiernan, MD, of New York-Presbyterian Hospital and Columbia University Medical Center in New York, told the Wall Street Journal that, at first glance, the study appears to give a “green light to go operating on everyone, but what it really does is shed a lot of light on the subset of patients who will benefit from surgery. The younger patient with relatively aggressive cancer is the patient who will benefit most from treatment,” said Dr. McKiernan, who was not involved in the study.

On Twitter, much of the discussion turned to the implications of the Scandinavian data on the U.S. population and whether the findings show a benefit for prostatectomy in older men.

“MAJOR benefit for surgery with long-term followup. NNT 8, benefit even for older men,” Matt Cooperberg, MD, of the University of California, San Francisco tweeted. “RP=fewer mets even for older men. >65 w/ HIGHRISK should be tx'ed,” he added.

“@nejm study makes clear that USPSTF answer of not looking is severely flawed,” tweeted Rajiv Singal, MD, of Toronto East General Hospital. “Need to better uncouple Dx from Rx and find these men.”

“I now begin my twice yearly flogging of the United States Preventive Services Task Force. Read a real trial people,” quipped Benjamin Davies, MD, of the University of Pittsburgh, including the New England Journal study in his tweet.

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