Article pour les cliniciens
Prostatectomie radicale ou attente vigilante dans le cancer de la prostate - Suivi de 29 ans.
PMID: 30575473
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Surgery - UrologyRelevance - 7/7
Intérêt médiatique - 6/7 -
Oncology - GenitourinaryRelevance - 7/7
Intérêt médiatique - 5/7 -
Médecine interne (voir sous-spécialités ci-dessous)Relevance - 6/7
Intérêt médiatique - 6/7 -
Médecine familiale (MF)/Médecine générale (MG)Relevance - 6/7
Intérêt médiatique - 5/7 -
Médecine interne générale - Soins primairesRelevance - 6/7
Intérêt médiatique - 5/7 -
Surgery - OncologyRelevance - 4/7
Intérêt médiatique - 4/7
Résumé (en anglais)
BACKGROUND: Radical prostatectomy reduces mortality among men with clinically detected localized prostate cancer, but evidence from randomized trials with long-term follow-up is sparse.
METHODS: We randomly assigned 695 men with localized prostate cancer to watchful waiting or radical prostatectomy from October 1989 through February 1999 and collected follow-up data through 2017. Cumulative incidence and relative risks with 95% confidence intervals for death from any cause, death from prostate cancer, and metastasis were estimated in intention-to-treat and per-protocol analyses, and numbers of years of life gained were estimated. We evaluated the prognostic value of histopathological measures with a Cox proportional-hazards model.
RESULTS: By December 31, 2017, a total of 261 of the 347 men in the radical-prostatectomy group and 292 of the 348 men in the watchful-waiting group had died; 71 deaths in the radical-prostatectomy group and 110 in the watchful-waiting group were due to prostate cancer (relative risk, 0.55; 95% confidence interval [CI], 0.41 to 0.74; P<0.001; absolute difference in risk, 11.7 percentage points; 95% CI, 5.2 to 18.2). The number needed to treat to avert one death from any cause was 8.4. At 23 years, a mean of 2.9 extra years of life were gained with radical prostatectomy. Among the men who underwent radical prostatectomy, extracapsular extension was associated with a risk of death from prostate cancer that was 5 times as high as that among men without extracapsular extension, and a Gleason score higher than 7 was associated with a risk that was 10 times as high as that with a score of 6 or lower (scores range from 2 to 10, with higher scores indicating more aggressive cancer).
CONCLUSIONS: Men with clinically detected, localized prostate cancer and a long life expectancy benefited from radical prostatectomy, with a mean of 2.9 years of life gained. A high Gleason score and the presence of extracapsular extension in the radical prostatectomy specimens were highly predictive of death from prostate cancer. (Funded by the Swedish Cancer Society and others.).
Commentaires cliniques (en anglais)
General Internal Medicine-Primary Care(US)
This study puts more wrinkles in the prostate cancer study. The choice to use watchful waiting versus radical prostatectomy is a nuanced decision and has to take frailty in context.
General Internal Medicine-Primary Care(US)
As an Internist, I have never been able to sort out what to do with in this situation. Although not at all my area of expertise, I can say if you are a relatively healthy male with a certain burden of disease and invasion, you would or would not benefit from a radical prostatectomy. Disclaimer - not my area of expertise.
Internal Medicine
Good information to have especially when patients need advice about whether to undergo the radical prostatectomy or participate in watchful waiting.
Internal Medicine
This long-term RCT data are really useful. It would have been nice to see whether there are subgroups who wouldn`t benefit from surgery, but there may not have been sufficient participants.
Oncology - Genitourinary
This article demonstrates improved survival with radical prostatectomy vs watchful waiting in long-term follow-up. While this trial certainly supports the practice of radical prostatectomy, I would caution applying the results to all patients. Patients with low Gleason score and no other aggressive features may not benefit as much as those with more aggressive disease. It is important to try to select patients well to maximize benefit and minimize harm.
Surgery - Oncology
Interesting paper. For me as a surgical oncologist, it has the value of long term followup in a frequent type of cancer.
Surgery - Oncology
Further guidance in a complicated decision pathway.
Surgery - Urology
Excellent methodology. It is not clear what is meant by moderately differentiated Prostate cancer in the inclusion criteria. The authors should have defined it better.
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