Surgery Is No Better Than Active Surveillance for Early-Stage Prostate Cancer

According to the findings of an important study lasting approximately 20 years, operating on low-risk, early-stage prostate cancers does not reduce mortality more than actively monitoring these patients. In other words, surgical outcomes in early-stage prostate cancer are no better than observation.

On 13 July, NEJMpublished the results of the Prostate Cancer Intervention Versus Observation Trial (PIVOT). The trial began in 1994, and its 731 participants with localized prostate cancer were followed for a median of 12.7 years.

Some of these patients with early-stage prostate cancerunderwent the prostate cancer operation known as radical prostatectomy , while the others were simply observed.

The 20-year study found that mortality was 61.3% in the surgery group (223 of 364 patients) and 66.8% in the observation group (245 of 367 patients). However, this difference of approximately 5 percent was not statistically significant (95% confidence interval [CI], −1.5 to 12.4; hazard ratio, 0.84; 95% CI, 0.70 to 1.01; P=0.06).

In subgroup analyses, patients in the intermediate-risk category who underwent surgery had lower all-cause mortality. However, among patients at low or high risk, surgery did not provide this advantage. In addition, loss of bladder control (urinary incontinence) and erectile difficulties (erectile dysfunction) were more common after surgery, as expected. Prostate cancer- or treatment-related difficulty with everyday activitieswas more frequent in the surgery group than the observation group during the first two years after diagnosis.

In conclusion, after approximately 20 years of follow-up in patients with localized / early-stage prostate cancer, surgery was not superior to active surveillance in reducing all-cause or prostate cancer-related mortality. Although surgery appeared to reduce the likelihood of local recurrence in this group, these recurrences were generally asymptomatic, causing no complaints. Surgery for early-stage prostate cancer also carried a higher rate of adverse effects than observation.

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