Evolving Care in Prostate Cancer

by Howard Wolinsky

Thirty years ago, researchers from Sweden, Finland, and Iceland embarked on a landmark study of nearly 700 men with prostate cancer.

The men were randomized to two groups; one underwent radical prostatectomy and the other, “watchful waiting” (WW), with treatment only for symptoms. They were followed for an average of 23 years. 80% are now deceased.

The Scandinavian Prostate Cancer Group published another report last week on its Number 4 study (SPCG-4) in the New England Journal of Medicine. It showed men who underwent radical prostatectomy lived an average 2.9 years longer than those undergoing the original crude approach of watchful waiting.

This doesn’t mean all men with prostate cancer ought to run out and undergo radical surgery. The researchers found that it was possible to predict which patients were more likely to die from prostate cancer based on the presence of extracapsular extension in biopsies and high Gleason scores (8 or 9).

He said there has been a sea change in prostate cancer diagnosis and treatment since the study launched in 1989. Prostate-specific antigen (PSA) screening and testing to monitor the disease has been common, but rare back then in Scandinavia. AS has developed as a strategy distinct from WW with new tools to follow the disease, including multiparametric MRI and fusion biopsies.

I was stunned to read that 695 men were randomly assigned to undergo surgery or to go untreated. Personally, I would have wanted more say in my fate. But these brave men took a bold step into the unknown to help future generations. We men with prostate cancer owe them a debt of gratitude.

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