Radical Prostatectomy Versus Surveillance

Various studies have questioned the appropriateness of aggressive treatment for localized disease and have suggested surveillance instead.4-9 Advocates for surveillance argue that early radical treatment for PC has not been proven to alter the natural history of the disease and thus treatment-associated morbidities, especially in younger patients, could not be justified.10 An often quoted Swedish study that suggests an advantage to surveillance has reported a 15-year cancer-specific survival of up to 81%.11 However, careful interpretation of the study reveals the following limitations: a preponderance of older patients (mean age of 70-72 years), and the majority of the reported cases had favorable histologies in the form of moderate and well-differentiated disease. Accordingly, this study cannot be applied to younger, healthier populations or patients with unfavorable histology. In contrast, another Swedish study has reported 63% mortality rates due to prostate cancer among patients who were managed expectantly with a follow-up exceeding 10 years.12

In a study by Albersten, a significant survival advantage for surgery over surveillance was noted in treating poorly differentiated disease (Gleason score 8-10).13 Moreover, a watchful waiting strategy is not free of complications. Local progression from prostate cancer can result in ureteral obstruction or bladder outlet obstruction. In a review by Aus and associates, 17% of patients who were managed expectantly underwent procedures to relieve upper tract obstruction and 41 had at least one channel transurethral resection of the prostate (TURP).12 Metastatic prostate cancer can cause severe bone pain, pathologic fracture, spinal cord compression and death.

Presently, the Scandinavian Prostate Cancer Group and the US Prostate Cancer Intervention Versus Observation Trial (PIVOT) are two large prospective randomized controlled studies comparing radical prostatectomy and watchful waiting as treatment modalities for localized prostate cancer.14 Until the results of these studies are available, prostate cancer remains the second leading cause of cancer death in men with a 50% suggested death rate in men who are diagnosed with a moderately well-differentiated disease and a life expectancy of 15 years or more.15 We believe that younger males would be best served by surgery, since they are at risk of their disease for many years. Watchful waiting should only be reserved for older patients with low Gleason scores.

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