Treatment of Early Localized Prostate Cancer

Management of Localized Prostate Cancer: Data at Last

Robert Dreicer, MD, MS, FACP, FASCO reviewing Hamdy FC et al. N Engl J Med 2016 Sep 14. D’Amico AV.N Engl J Med 2016 Sep 14.

Mortality was similar with active monitoring, prostatectomy, or radiotherapy during 10 years of follow-up.

Determining a management strategy for men with low-risk, clinically localized prostate cancer identified by prostate-specific antigen (PSA) testing remains a challenge given the paucity of data. To compare three initial approaches for such patients, U.K. investigators randomized 1643 men (median age, 62 years) with localized disease (median PSA, 4.6 ng/mL) to active monitoring (regular PSA testing and curative or palliative intervention with progression), radical prostatectomy, or radiotherapy (3–6 months of androgen-deprivation therapy and 74 Gy).

Of these patients, 76% had clinical stage-T1c disease, and 77% had tumors with a Gleason score of 6. More than 70% of patients received the specified management within 9 months of randomization. Of the 545 men who received active monitoring, 53% ultimately underwent radiotherapy or surgery.

At a median 10 years of follow-up, prostate-specific mortality (the primary outcome) was similar with each strategy: 8 patients died with active monitoring, 5 died with prostatectomy, and 4 died with radiotherapy. The rate of metastasis was higher with active monitoring than with local therapy (P=0.004). The investigators estimated that to avoid having one patient develop metastatic disease, 27 would need to undergo prostatectomy, and 33 would need to receive radiotherapy.


An editorialist noted the trend in survival improvement with local therapy versus active monitoring overall and, specifically, in men 65 years or older. That said, the investigators note that this study observed a low rate of mortality from prostate cancer, irrespective of management approach.

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