SPCG-4 trial: Update on watchful waiting versus radical prostatectomy

In 2005, the Scandinavian Prostate Cancer Group Study 4 (SPCG-4) reported that radical prostatectomy improved prostate cancer survival compared with watchful waiting after a median of 8.2 years of follow-up. At the 24th Annual EAU Congress in Stockholm, Sweden the results after 3 more years of follow-up were reported by Professor Lars Holmberg from Uppsala, Sweden. The SPCG-4 trial – which predominantly included men whose prostate cancer was not detected by PSA screening - was the first randomized trial to show that radical prostatectomy reduces the risk of prostate cancer mortality and the risk of developing metastases.

Lars Holmberg: "Key questions following our previous analyses of this trial, which were based on a median of 8.2 years of follow-up, include whether the absolute and relative benefits of surgical treatment would increase during longer follow-up, as we hypothesized; whether overall mortality would remain reduced; whether the benefit is larger among younger than among older patients; and whether histopathologic parameters can predict lethal outcome following surgery. We think the answer may well be affirmative".

The conclusion of the study is that radical prostatectomy reduces prostate cancer mortality and risk of metastases with little or no further increase in benefit 10 or more years after surgery.

Lars Holmberg: "One of the most striking results of this study was the fact that, in a follow-up of side effects, symptoms and quality of life within the randomised study, the symptom profile was different in the two randomisation groups but the overall rating of quality of life was similar. This may mean that the side effects of radical prostatectomy wear off, people get used to it perhaps." This indicates that well structured pre-treatment information, understanding of the patient's preferences and support during follow-up are central to the management of prostate cancer.

"Radical prostatectomy has changed the natural history of prostate cancer. Furthermore it is not sufficient to only to perform PSA tests in post-prostatectomy patients, we do need more tests", says Holmberg.

The SPCG-4 study continues its follow-up. The randomised patients are becoming older men by now which may again result in new and challenging data in the future.

Source: European Association of Urology