{"entity":{"id":"paper-bill-axelson-spcg-4-29-year-nejm-2018","kind":"paper","name":"SPCG-4: radical prostatectomy or watchful waiting in prostate cancer, 29-year follow-up","aka":["SPCG-4","Bill-Axelson 2018","Scandinavian Prostate Cancer Group Study Number 4"],"tldr":"Men with prostate cancer found because it caused a lump or symptoms, randomised in the years before PSA testing, were followed for nearly thirty years. Surgery roughly halved the chance of dying of prostate cancer and added an average of 2.9 years of life.","summary":"Anna Bill-Axelson and the Scandinavian Prostate Cancer Group randomised 695 men with clinically detected localised prostate cancer to watchful waiting or radical prostatectomy between October 1989 and February 1999, and followed them through 2017.\n\nThe critical word is clinically detected. These men were found because something was abnormal, not because a blood test was raised, so their cancers were larger and more advanced than the ones a screening programme finds. That is why SPCG-4 is positive and PIVOT, which enrolled a largely prostate-specific antigen-detected population five years later, is not. Read together, the two trials say that the benefit of radical treatment depends on how the cancer was found, which is the single most useful thing a man with newly diagnosed localised disease can be told.","asOf":"2026-09-25","links":[{"label":"N Engl J Med 2018","url":"https://doi.org/10.1056/nejmoa1807801"},{"label":"PubMed","url":"https://pubmed.ncbi.nlm.nih.gov/30575473/"}],"tags":["prostate-evidence"],"related":["paper-wilt-pivot-prostatectomy-observation-nejm-2017","paper-protect-nejm-2016","paper-protect-15-year-nejm-2023","surgery-roadmap","prostate-roadmap"],"cancers":["prostate","prostate-intermediate-risk","prostate-high-risk"],"sections":["surgery"],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["prostatectomy","gleason-grade-group","overdiagnosis","other-cause-mortality","overtreatment"],"trials":[],"people":[],"bottlenecks":["b-overdiagnosis","b-surgery-radiation-innovation","b-toxicity-qol"],"keyPapers":[],"journals":["nejm"],"dependsOn":[],"notes":[],"journal":"New England Journal of Medicine","year":2018,"doi":"10.1056/nejmoa1807801","pmid":"30575473","authors":"Bill-Axelson A, Holmberg L, Garmo H, et al.","paperType":"rct","findings":["By 31 December 2017, 261 of 347 men in the radical prostatectomy group and 292 of 348 in the watchful waiting group had died.","71 deaths in the prostatectomy group and 110 in the watchful waiting group were from prostate cancer: relative risk 0.55 (95 percent confidence interval 0.41 to 0.74; P less than 0.001), an absolute difference of 11.7 percentage points (5.2 to 18.2).","The number needed to treat to avert one death from any cause was 8.4.","At 23 years, a mean of 2.9 extra years of life were gained with radical prostatectomy.","Among men who had surgery, extracapsular extension carried 5 times the risk of prostate cancer death, and a Gleason score above 7 carried 10 times the risk of a score of 6 or lower."],"whatItMeans":"The clearest evidence that radical treatment of localised prostate cancer saves lives when the cancer was found clinically rather than by a blood test, and the clearest single statement of what grade does: a Gleason score above 7 carried ten times the risk of death of a score of 6 or lower in the same trial.","caveats":["Enrolment ran from 1989 to 1999 and the population was clinically detected, with a median prostate-specific antigen far above what a screening programme produces; the result does not transfer to screen-detected low-risk disease.","Watchful waiting in this trial is not modern active surveillance, which uses magnetic resonance imaging and repeat biopsy and treats radically when the cancer progresses.","Surgical technique, staging and adjuvant treatment have all changed in the intervening thirty years."],"changedPractice":true,"participants":695},"route":"/key-papers/paper-bill-axelson-spcg-4-29-year-nejm-2018/","neighbours":{"paper":[{"id":"paper-damico-risk-groups-jama-1998","kind":"paper","name":"D'Amico risk groups: biochemical outcome after radical prostatectomy, external beam radiotherapy or brachytherapy","route":"/key-papers/paper-damico-risk-groups-jama-1998/"},{"id":"paper-wilt-pivot-prostatectomy-observation-nejm-2017","kind":"paper","name":"PIVOT: follow-up of prostatectomy versus observation for early prostate cancer","route":"/key-papers/paper-wilt-pivot-prostatectomy-observation-nejm-2017/"},{"id":"paper-protect-nejm-2016","kind":"paper","name":"ProtecT: 10-year outcomes after monitoring, surgery or radiotherapy for localised prostate cancer","route":"/key-papers/paper-protect-nejm-2016/"},{"id":"paper-protect-15-year-nejm-2023","kind":"paper","name":"ProtecT: fifteen-year outcomes after monitoring, surgery or radiotherapy for prostate cancer","route":"/key-papers/paper-protect-15-year-nejm-2023/"}],"roadmap":[{"id":"prostate-roadmap","kind":"roadmap","name":"Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch","route":"/roadmaps/prostate-roadmap/"},{"id":"surgery-roadmap","kind":"roadmap","name":"Surgery roadmap: radical operations → less surgery → no surgery when a drug has done the work","route":"/roadmaps/surgery-roadmap/"}],"cancer":[{"id":"prostate-high-risk","kind":"cancer","name":"Localised prostate cancer, high and very high risk","route":"/cancers/prostate-high-risk/"},{"id":"prostate-intermediate-risk","kind":"cancer","name":"Localised prostate cancer, intermediate risk","route":"/cancers/prostate-intermediate-risk/"},{"id":"prostate","kind":"cancer","name":"Prostate cancer","route":"/cancers/prostate/"}],"section":[{"id":"surgery","kind":"section","name":"Surgery & Interventional","route":"/fronts/surgery/"}],"term":[{"id":"gleason-grade-group","kind":"term","name":"Gleason score / Grade Group","route":"/terms/gleason-grade-group/"},{"id":"other-cause-mortality","kind":"term","name":"Other-cause mortality","route":"/terms/other-cause-mortality/"},{"id":"overdiagnosis","kind":"term","name":"Overdiagnosis","route":"/terms/overdiagnosis/"},{"id":"overtreatment","kind":"term","name":"Overtreatment","route":"/terms/overtreatment/"},{"id":"prostatectomy","kind":"term","name":"Radical prostatectomy","route":"/terms/prostatectomy/"}],"bottleneck":[{"id":"b-overdiagnosis","kind":"bottleneck","name":"Overdiagnosis and false alarms","route":"/bottlenecks/b-overdiagnosis/"},{"id":"b-surgery-radiation-innovation","kind":"bottleneck","name":"Surgery and radiotherapy cure most, get least","route":"/bottlenecks/b-surgery-radiation-innovation/"},{"id":"b-toxicity-qol","kind":"bottleneck","name":"Toxicity and quality of life are undervalued","route":"/bottlenecks/b-toxicity-qol/"}],"journal":[{"id":"nejm","kind":"journal","name":"New England Journal of Medicine","route":"/journals/nejm/"}]}}