By the end of 2009, 367 (53%) of the 695 men had died, 136 (37%) from prostate cancer. The absolute and relative risk reductions for cancer-specific mortality for prostatectomy relative to watchful waiting were 6.1% and 38%, respectively. For all-cause mortality, these reductions were 6.6% and 25%, respectively, again, in favor of surgery. Subgroup analysis found that these differences were observed even among men with low-risk disease (Gleason score <7 and PSA <10 ng/ml) but that there was no difference in outcomes between groups for men aged >65.
The findings of the subgroup analyses—that the benefits of surgery over watchful waiting persist across risk groups but not across age strata—are somewhat counterintuitive. In contrast, the Prostate Cancer Intervention Versus Observation Trial (PIVOT), recently reported at the American Urological Association annual meeting, randomized men between surgery and observation between 1994 and 2002. This cohort had mostly screen-detected tumors, and a survival benefit was found at 10 yr only for those with higher-risk tumors.
An analysis of older men treated conservatively for localized prostate cancer found that for those with high-grade tumors, likelihood of cancer-specific mortality approached 25% at 10 yr, even for those aged >80 at diagnosis , yet treatment decisions in the United States tend to reflect age more than disease risk, leading to high rates of both overtreatment of low-risk disease and undertreatment of high-risk disease among older men . Other recent studies have likewise highlighted the greater role that comorbidity, rather than age alone, should play in driving both screening and management decisions  and . Ultimately, the SPCG-4 trial provides important evidence in favor of intervention for localized prostate cancer, but further work is needed to identify which men will ultimately benefit most from treatment.
Conflicts of interest
The author has nothing to disclose.
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University of California, San Francisco, Urology, 3025 Scott St., San Francisco, CA 94123, USA
© 2011 Published by Elsevier B.V.