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NLM Director’s Comments Transcript
Prostate Cancer Surgery not better than Watchful Waiting: 09/10/2012

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Greetings from the National Library of Medicine and

Regards to all our listeners!

I'm Rob Logan, Ph.D. senior staff National Library of Medicine for Donald Lindberg, M.D, the Director of the U.S. National Library of Medicine.

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Prostate removal surgery does not save lives compared to active surveillance for most men with localized prostate cancer, suggest a comprehensive study and accompanying editorial recently published in the New England Journal of Medicine.

In a 15-year clinical trial of 731 American men with localized prostate cancer, there was not a statistically meaningful difference in mortality between those who were randomly assigned to obtain prostate removal surgery, and those who randomly received active surveillance, or what is sometimes called ‘watchful waiting.’

Localized prostate cancer occurs when a biopsy reveals cancer is contained within the prostate gland area. Localized prostate cancer often is an example of early stage prostate cancer; both of which are detected sometimes by a PSA screening test.

About half of the study’s 731 male participants died; 171 deaths occurred among those randomly assigned to the prostate removal surgical group and 183 died in the active surveillance group. The study’s 21 authors report these mortality differences are not statistically significant.

However, most participant deaths were not from prostate cancer. Only 52 men (or about seven percent) of the 354 trial participants with localized prostate cancer died from prostate cancer. Similarly among those who died from prostate cancer, the mortality rates between the prostate removal and active surveillance groups were not statistically meaningful.

The only meaningful differences between the prostate removal surgery and active surveillance groups occurred within a small group with localized prostate cancer who also had the highest initial PSA test scores. Among these participants, there were 13 percent fewer deaths in the surgery compared to the active surveillance group (which is statistically significant).

The American Cancer Society reports about 28,000 American men die annually and 242,000 new cases of prostate cancer are estimated to occur each year. PSA (or prostate specific antigen) blood tests have been a widely used screening tool in prostate cancer checkups for men after age 40.

The clinical trial, which took place from 1994-2002, was conducted by the Prostate Cancer Intervention versus Observation Trial Study group from multiple university medical centers throughout the U.S. The research was co-sponsored by the Agency for Healthcare Research and Quality, the National Cancer Institute, and the U.S. Department of Veterans Affairs.

An accompanying editorial suggests the current study is among the most comprehensive assessments of surgery versus surveillance options for prostate cancer patients to date. However, the editorial’s authors add the aggregate findings from the current and similar studies do not provide definitive answers about the wisdom of surgery versus surveillance, or broader issues such as the wisdom of using PSA blood tests to screen for prostate cancer.

In a recent podcast, we discussed the U.S. Preventive Services Task Force’s recent recommendation PSA blood tests should not be used to screen for prostate cancer in men. The Task Force (an independent panel of experts authorized by Congress to recommend preventive services for patients) found the PSA test’s risks outweighed its benefits.

While current research may not resolve the uncertainty in making some prostate cancer clinical decisions, the editorial’s authors note there is sufficient evidence to suggest a path for physicians and patients to follow.

The editorial’s authors ask rhetorically and we quote; “what is a rational approach to control this disease’ (end of quote)? They respond (and we quote): ‘The most efficient solution will probably include biopsy only for men with lethal cancer, treatment focused on this type of cancer, and individualized treatment approaches’ (end of quote).

The authors conclude prostrate cancer is a spectrum of diseases and effective treatment should require aggressive interventions based on high-risk tumors.’s prostate cancer health topic page covers some of the risks and benefits of PSA, and prostate cancer screening, and treatment. A helpful explanation about the risks and benefits of treatment options including surgery and surveillance for localized prostate cancer (provided by Agency for Healthcare Research and Quality) can be found in the ‘prevention/screening’ section of’s prostate cancer health topic page. The U.S. Preventive Task Force’s recent prostate cancer screening recommendations also are available in the ‘prevention/screening’ section.

Additional background information about localized prostate cancer (also provided by the Agency for Healthcare Research and Quality) is available in the ‘health check tools’ section. An introduction to treatment options for men with early-stage prostate cancer (provided by the National Cancer Institute) can be found in the ‘treatment’ section.’s prostate cancer health topic page additionally contains links to the latest pertinent journal research articles, which are available in the ‘journal articles’ section. Links to related clinical trials that may be occurring in your area are available in the ‘clinical trials’ section. From the prostate cancer health topic page, you can sign up to receive email updates with links to new information as it becomes available on MedlinePlus.

To find’s prostate cancer health topic page, type ‘prostate cancer’ in the search box on’s home page, then, click on ‘Prostate cancer (National Library of Medicine).’

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