Compared with Observation, Prostate Cancer Surgery Often Not Worth Potential Harms in Patients with Low or Low-Intermediate Risk Prostate Cancer
BACKGROUND:
Prostate cancer surgery is associated with important and persistent side effects, notably urinary and erectile dysfunction. Furthermore, prostate cancer most commonly occurs in older men and, even if left untreated, often does not cause morbidity and mortality. Therefore, surgical intervention should be performed only in individuals having higher risk cancers and a sufficiently long life expectancy that justifies side effect risk. Two randomized trials (SPCG4 and the VA-CSP #407: PIVOT) have compared surgery to conservative management for localized prostate cancer, but the applicability of these trials to contemporary practice remains uncertain. This study analyzed the long-term results from SPCG4 and PIVOT (adjusting for considerations such as recent advances in therapies) and data from two contemporary non-VA cohorts—one managed with active surveillance, and the other treated surgically at a high-volume academic center—to create an individualized prediction model for prostate cancer mortality comparing immediate surgery at a high-volume center to active surveillance. Researchers determined whether the relative risk of prostate cancer mortality with surgery versus observation varied by baseline risk. They then used various estimates of relative risk to estimate 15-year mortality with and without surgery.
FINDINGS:
- Compared with observation, surgery was associated with negligible benefit for men with low-risk prostate cancer (<1 percentage point mortality reduction at 15 years) and small benefit for men with low–intermediate risk prostate cancer (≤5% mortality reduction).
- Surgical benefits were modestly greater (6–9%) in men with higher risk disease, but effects varied widely.
- There was no evidence that relative risk varied by baseline risk.
IMPLICATIONS:
- Observation or active surveillance should be the treatment of choice for men with low-risk or low–intermediate risk prostate cancer.
- Integration of findings with a life-expectancy model is needed to allow patients to make informed treatment decisions given their oncologic risk, risk of death from other causes, and estimated surgery effects. This model would be of value both for clinical practice and for policy guidance and is planned by the investigators.
LIMITATIONS:
- Findings are based on the results of high-volume surgeons at a major academic medical center, where surgeons generally have more experience than those in community settings.
AUTHOR/FUNDING INFORMATION:
Drs. Langsetmo, Dahm, and Wilt are with the Minneapolis VA Medical Center. Drs. Wilt and Langsetmo are also with HSR’s Center for Care Delivery and Outcomes Research (CCDOR).
Vickers A, Vertosick E, Langsetmo L, Dahm P, Steineck G, Wilt TJ. Estimating the Effect of Radical Prostatectomy: Combining Data from the SPCG4 and PIVOT Randomized Trials with Contemporary Cohorts. Journal of Urology. June 12, 2024; online ahead of print.
