Remarkably, little evidence exists about the comparative benefits and harms of available treatment strategies.
Which treatment is best for localized prostate cancer is not well established. To compare treatment strategies, investigators reviewed 473 observational studies and 18 randomized clinical trials (RCTs) in which biochemical or clinical outcomes were reported.
Major treatment options were compared in only three RCTs. One RCT involved primarily men whose prostate cancer was not identified through prostate-specific antigen (PSA) screening; compared with watchful waiting, radical prostatectomy lowered all-cause mortality (30% vs. 24%) and cancer-specific mortality (15% vs. 10%) at 10 years and was effective only among men younger than 65 (Journal Watch May 20 2005). A small RCT showed no benefit, and another small RCT showed that radical prostatectomy led to less disease recurrence than did external-beam radiation therapy. Results in the observational studies were highly variable. Erectile dysfunction was common after all treatments, and urinary leakage was more likely after radical prostatectomy than after other treatments.
Comment: Remarkably, we have limited evidence to guide treatment decisions for a condition that is diagnosed in about 200,000 men every year in the U.S. Several costly and risky treatments are available, but we lack conclusive evidence about their comparative benefits and harms. Several additional clinical trials (such as the PIVOT study, in which surgery and watchful waiting are being compared and which involves many men with PSA-detected cancers) are under way.
— Richard Saitz, MD, MPH, FACP, FASAM
Published in Journal Watch General Medicine April 24, 2008
Wilt TJ et al. Systematic review: Comparative effectiveness and harms of treatments for clinically localized prostate cancer. Ann Intern Med 2008 Mar 18; 148:435.