Prostate Cancer: Newest Study Shows No Change in 15-Year Mortality Regardless of Treatment Strategy

Jennifer Middleton, MD, MPH
Posted on March 27, 2023

A large randomized controlled trial (RCT) of men with prostate cancer in the United Kingdom has found that active monitoring, prostatectomy, and radiotherapy resulted in similar rates of cancer-related mortality after a median of 15 years. Published earlier this month, this study furthers the argument that many people with prostate cancers don’t need aggressive treatment.

The study authors enrolled 1,643 persons in the United Kingdom between 50 and 69 years of age with a diagnosis of localized prostate cancer and randomly assigned them to one of three treatment arms: active monitoring, prostatectomy, and radiotherapy. Their primary outcome was death from prostate cancer, and secondary outcomes included death from any cause, development of metastases, and disease progression. They found that, “[a]fter fifteen years of follow-up prostate cancer-specific mortality was low regardless of the treatment assigned": The hazard ratio for death from prostate cancer compared with the active monitoring group was 0.66 (95% CI, 0.31 to 1.39) for the prostatectomy group and 0.88 (95% CI, 0.44 to 1.74) in the radiotherapy group. The researchers did find differences among the secondary outcomes:

Radical treatments (prostatectomy or radiotherapy) reduced the incidence of metastasis, local progression, and androgen-deprivation therapy by half, as compared with active monitoring. However, these reductions did not translate into differences in mortality at 15 years, a finding that emphasizes the long natural history of this disease.

The United States Preventive Services Task Force (USPSTF) gives prostate cancer screening using the prostate specific antigen (PSA) serum test a C recommendation for men 55 to 69 years of age and a D recommendation for men older than 70 years. In 2018, when the USPSTF changed the recommendation for men 55 to 69 years of age from a D to a C, Dr. Lin described in a Community Blog post that this shift was not based on any new study data or treatment changes. The trials cited in his post (ProtecT and PIVOT) had similar outcomes to this newest trial; these trials were smaller, but participants in active monitoring, surgery, and radiotherapy all had equivalent mortality outcomes.

As more urologists embrace watchful waiting, the balance of benefits to harms of PSA screening may be shifting. Because watchful waiting would theoretically reduce the risk of harms from active treatment (most commonly incontinence and/or impotence), having a positive PSA screening test may be less likely to result in harm. That said, these studies also do not show a benefit to identifying localized cancers. The American Academy of Family Physicians declined to endorse the USPSTF 2018 update for prostate cancer screening, stating that “there is little evidence that routinely doing so improves patient-oriented outcomes.”

The debate is likely to continue, but this latest study provides additional information to share with patients; patient-centered decision-making is one framework to consider when discussing whether to order a screening PSA, as well as determining a plan for patients with newly identified localized prostate cancer. You can read more in the AFP By Topic on Cancer, which includes this 2018 article on “Prostate Cancer: Making Decisions About Treatment.”