Treating prostate cancer

More than 40 000 men in the United Kingdom are diagnosed as having prostate cancer each year and the incidence has tripled since the 1970s,1 largely because of efforts to promote early detection using prostate specific antigen tests. Men with localised prostate cancer face a bewildering array of treatment options, including watchful waiting, active surveillance, external beam radiotherapy, brachytherapy, cryotherapy, high intensity focused ultrasound, and radical prostatectomy. Until now men have had to make their choice without the help of evidence from good quality randomised controlled trials. The results of the recently published Prostate cancer Intervention Versus Observation Trial (PIVOT) are welcome,2 but how will they help men diagnosed today as having localised prostate cancer to make a choice about treatment?

PIVOT recruited 731 North American men with localised prostate cancer between 1994 and 2002 and randomised them to radical prostatectomy or watchful waiting. At the time of recruitment, testing for prostate specific antigen was the norm, and the case mix reflects that, with its preponderance of low risk cases. More than half the patients had died at the time of analysis. Randomisation to surgery was associated with a non-significant 2.9% absolute reduction at 12 years in the …