Radical prostatectomy vs watchful waiting


e-mail: rogerkirby@theprostatecentre.com

It was a rather unfortunate accident of timing that the paper by Whelan [1] arguing that patients with localized prostate cancer fare just as well with watchful waiting as with surgery was published in the same month that a Scandinavian group reported the results of their randomized study comparing the two treatments [2]. Over a 10-year observation period, radical prostatectomy (RP) reduced disease-specific mortality, overall mortality (P = 0.04), and the risks of metastasis and local progression (P = 0.001) in the surgically managed group of 347 men (Fig. 1). The authors concluded that although the absolute reduction in the risk of death after 10 years is small, the reductions in the risk of metastasis and local tumour progression are substantial [2].

Figure 1.

The cumulative incidence of a, metastases and b, death from any cause in men treated by watchful waiting or RP over 10 years of follow-up. Reproduced with permission from Bill-Axelson et al.[2].

Over 30 000 men are diagnosed annually in the UK with prostate cancer, and while watchful waiting is an excellent option for older men with low-risk, well-differentiated cancers, as confirmed by the recently published data of Albertson et al.[3], patients with higher Gleason scores (≥7) fare much less well over time [4]. Roehl et al.[5] recently reported the excellent outcome and low morbidity in 3478 patients treated by RP with 10 years of follow-up. Not surprisingly, patients with poorly differentiated tumours fare less well with surgery [5] and for this small subgroup external beam radiotherapy with adjuvant androgen ablation is probably now the best management option [6].

Currently, the debate about the management of patients with medium-risk localized prostate cancer (i.e. Gleason score 7), who constitute the vast majority of the case load, has moved on from RP vs watchful waiting to RP vs brachytherapy. With excellent long-term data now being reported for this treatment [7], the pertinent question is now whether brachytherapy or RP is the right treatment choice for an individual patient. Moreover, retropubic RP is developing rapidly, with laparoscopic and robotic assistance promising less morbidity and a shorter hospital stay, and the goal-posts are continuing to move. With >10 000 deaths from prostate cancer each year in the UK, and far more than this worldwide, watching and waiting while men progress and eventually die from this very prevalent disease hardly seems the way to turn back the advancing tide.