Advances in Prostate Cancer: 2014

Treatment of Localized Disease

Another ongoing controversy involves the impact of treating men with localized prostate cancer. The only two randomized studies reporting results are the Scandinavian trial^[7] and the PIVOT trial,^[8] with conflicting findings. Both studies compared watchful waiting with radical prostatectomy for localized prostate cancer.

After 12 years of follow-up, the PIVOT trial showed a 2.6% nonsignificant improvement in survival in men whose prostate cancer was detected primarily by screening. However, a significant reduction in mortality was detected in men with PSAs greater than 10 ng/mL.

By contrast, the Scandinavian trial reported updated 18-year results showing that men who underwent radical prostatectomy had significantly better overall survival, better cancer-specific survival, and a lower risk for metastatic disease than those who did not undergo surgery. The surgery group had a 12.7% higher overall survival an 11% lower risk of dying from prostate cancer, and a 12.2% lower chance of developing metastatic disease at 18-year follow-up. The benefit was greatest in men younger than 65 years of age and those with intermediate-risk prostate cancer. The men older than 65 years, however, had no improvement in overall survival or cancer-specific survival.

Comparisons between the two studies are difficult because only a small proportion of cancers in the men in the Scandinavian trial were detected by screening and the mean PSA was 13 ng/mL, compared with a median PSA of 7.8 ng/mL in the PIVOT trial. In addition, the duration of follow-up was longer in the Scandinavian study, and the PIVOT trial was more likely to have found more non–life-threatening tumors.

Regardless, radical prostatectomy is clearly lowering mortality for some men; the challenge is to identify who they are. Genetic testing is improving and may offer a solution. We hope that other studies in progress will provide important information about the relative benefits of radical prostatectomy.

Cite this: Gerald Chodak. Advances in Prostate Cancer: 2014 - Medscape - Dec 11, 2014.

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