Overdiagnosis leads to overtreatment of low-risk prostate cancer. Both traditional treatment options for prostate cancer—radical prostatectomy and radiotherapy—are associated with urinary incontinence, erectile dysfunction, and issues with bowel function.22,23
The Prostate Cancer Intervention vs Observation Trial (PIVOT),24 the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4),25 and the Prostate Testing for Cancer and Treatment (ProtecT) trial,22,23 are the major RCTs that looked at the outcomes of treatment modalities for localized prostate cancer in the modern era of PSA testing.
PIVOT compared passive observation with radical prostatectomy.24 After 20 years of follow-up on 731 patients, the researchers concluded that radical prostatectomy did not reduce all-cause or prostate cancer–related mortality (TABLE 3).24
SPCG-4showed survival benefits for men who underwent radical prostatectomy compared with men in a watchful waiting group, but only 5% of the study cohort had cancer detected by PSA screening (TABLE 4).25 The rest had either palpable tumors or symptoms of a tumor.
ProtecT, which followed patients with localized prostate cancer for more than 10 years,compared the outcomes and adverse effects of active surveillance, radical prostatectomy, and radiotherapy.23 Prostate cancer–specific mortality was low irrespective of the treatment,23 and there was no significant difference in all-cause mortality or prostate cancer–specific mortality between the 3 treatment groups.23 The active surveillance group had considerably fewer adverse events.22,23 The incidence rates of erectile dysfunction and urinary incontinence at the 1- and 6-year follow-up marks are outlined in TABLE 5.22
