Prostatectomy

Posted by Graham McMahon • May 6th, 2011

After about 13 years of follow-up, men <65 years of age with prostate cancer diagnosed on the basis of obstructive urinary symptoms (rather than elevated prostate-specific antigen levels) and assigned to radical prostatectomy, as compared with watchful waiting, have improved survival.  Bill-Axelson et al. present their findings in an Original Article this week in NEJM.

Determining whether there is a survival benefit for men with low-risk [prostate cancer] is relevant in light of the risk of overdiagnosis resulting from PSA testing and the adverse events associated with therapy.

Clinical Pearls

As compared to watchful waiting, was radical prostatectomy associated with a reduction in overall mortality?

The cumulative incidence of death at 15 years was 46.1% in the radical-prostatectomy group and 52.7% in the watchful-waiting group (a difference of 6.6 percentage points; 95% confidence interval [CI], -1.3 to 14.5), corresponding to a relative risk of death in the radical-prostatectomy group of 0.75 (95% CI, 0.61 to 0.92; P=0.007) and a number needed to treat of 15.

As compared to watchful waiting, was radical prostatectomy associated with a reduction in prostate-specific mortality?

The cumulative incidence of death from prostate cancer at 15 years was 14.6 in the radical-prostatectomy group and 20.7 in the watchful-waiting group (a difference of 6.1 percentage points; 95% CI, 0.2 to 12.0), corresponding to a relative risk of death in the radical-prostatectomy group of 0.62 (95% CI, 0.44 to 0.87; P=0.01).

Morning Report Questions

Q: What subgroups of patients had a differential outcome following radical prostatectomy?

A: The interaction term between age at randomization (<65 years vs. greater than/equal to 65 years) and treatment was significant with respect to overall mortality (P=0.003) and remained so when age was considered as a continuous variable (P=0.001). The PSA level at the time of randomization (<10 vs. greater than/equal to 10 ng per milliliter) and the Gleason score (<7 vs. greater than/ equal to 7) did not alter the effect of radical prostatectomy.

Q: What were the most common adverse effects associated with radical prostatectomy?

A: The most common symptom reported postoperative was impotence (58% of patients), followed by urinary leakage (32%).

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