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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.
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.
The 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.
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.
Long-term data support active surveillance as a safe choice for low and much intermediate-risk disease, while the lower metastasis rate with treatment informs the discussion for men with longer life expectancy.
The trial that made observation a defensible choice for low-risk prostate cancer found by a blood test, and that supplied the number a man needs when weighing surgery: the progression it prevents is mostly progression on a scan or a blood test, and the harms it causes are felt every day.
Most men with low- and favourable intermediate-risk prostate cancer can safely choose monitoring, and treatment choice should weigh urinary, sexual and bowel side effects against a small difference in progression.
The D'Amico system, refined by the NCCN, remains the framework for the very-low to very-high-risk categories used on this site's prostate pages.
Shares ProtecT: fifteen-year outcomes after monitoring, surgery or radiotherapy for prostate cancer, Other-cause mortality, Overtreatment, Overdiagnosis and the tag prostate-evidence.
Shares Radical prostatectomy, Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk, Overdiagnosis and false alarms and the tag prostate-evidence.
Shares Radical prostatectomy, Gleason score / Grade Group, Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk and the tag prostate-evidence.
Shares D'Amico risk groups: biochemical outcome after radical prostatectomy, external beam radiotherapy or brachytherapy, Localised prostate cancer, intermediate risk, Overdiagnosis and false alarms, 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 and the tag prostate-evidence.
Shares Overtreatment, Overdiagnosis, Gleason score / Grade Group, Overdiagnosis and false alarms and the tag prostate-evidence.
Shares Radical prostatectomy, Gleason score / Grade Group, Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk and the tag prostate-evidence.
Shares Overtreatment, Overdiagnosis, Overdiagnosis and false alarms, 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 and the tag prostate-evidence.
Shares Overtreatment, Overdiagnosis, Overdiagnosis and false alarms, 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 and the tag prostate-evidence.