Abstract
Objective: The aim of this study was to compare the outcome of immediate versus delayed radical prostatectomy (RP) in men with low-grade prostate cancer. Materials and methods: The study included a nationwide population-based cohort in the National Prostate Cancer Register of Sweden, of 7608 men with clinically localized, biopsy Gleason score 6 prostate cancer who underwent immediate or delayed RP in 1997–2007. Multivariable models compared RP pathology, use of salvage radiotherapy and prostate cancer mortality based on timing of RP (< 1, 1–2 or >2 years after diagnosis). Median follow-up was 8.1 years. Results: Men undergoing RP more than 2 years after diagnosis had a higher risk of Gleason upgrading [odds ratio 2.93, 95% confidence interval (CI) 2.34–3.68] and an increased risk of salvage radiotherapy [hazard ratio (HR) 1.90, 95% CI 1.41–2.55], but no significant increase in prostate cancer-specific mortality (HR 1.85, 95% CI 0.57–5.99). In competing risk analysis, 7 year prostate cancer-specific cumulative mortality was similar, at less than 1%, for immediate RP and active surveillance regardless of later intervention. Limitations of this study include the lack of data on follow-up biopsies and the limited follow-up time. Conclusion: Men undergoing RP more than 2 years after diagnosis had more adverse pathological features and second line therapy, highlighting the trade-off in deferring immediate curative therapy. However, men with delayed RP constitute a minority with higher risk cancer among the much larger group of low-risk men initially surveilled, and the overall risk of prostate cancer mortality at 7 years was similarly low with immediate RP or active surveillance.
Highlights
Treatment of favorable-risk prostate cancer is curative in the vast majority of men,[1] but can have a significant negative impact on quality of life.[2]
Men undergoing radical prostatectomy (RP) more than 2 years after diagnosis had a higher risk of Gleason upgrading and an increased risk of salvage radiotherapy (HR 1.90, 95%CI 1.41-2.55), but no significant increase in prostate cancer (PCa)-specific mortality (HR 1.85, 95%CI 0.57-5.99)
Men with delayed RP constitute a minority with higher-risk cancer among the much larger group of low-risk men initially surveilled and the overall risk of prostate cancer mortality at 7 years was low with immediate RP or AS
Summary
Treatment of favorable-risk prostate cancer is curative in the vast majority of men,[1] but can have a significant negative impact on quality of life.[2]. The median follow-up across active surveillance programs was only 3 years, and the longest median follow-up of any individual cohort was 7 years.[6] More recently, Klotz et al reported updated follow-up of the Sunnybrook cohort (median follow-up of 6 years from first biopsy) in which 1.5% had died from prostate cancer and an additional 1.3% developed metastatic disease.[7] Updated data from the Johns Hopkins active surveillance program (median follow-up of 5 years) reported 2 prostate cancer deaths (0.15%) and 0.4% with metastatic disease.[8]
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