COMMENTARY

Advances in Prostate Cancer: 2014

Gerald Chodak, MD

Disclosures

December 11, 2014

In This Article

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.

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