A randomized trial begun in 1989 compared radical prostatectomy with watchful waiting in men who had localized prostate cancer. In a follow-up study conducted 29 years later, researchers analyzed whether the survival benefit after radical prostatectomy continued and whether histopathological variables predicted long-term prognosis in the surgical group.

Between 1989 and 1999, a total of 695 men with localized prostate cancer were randomly assigned to radical prostatectomy or watchful waiting in health centers in Sweden, Finland, and Iceland. Participants had to be younger than age 75 and have a life expectancy of more than 10 years, no other cancer that would be expected to shorten survival, a prostate-specific antigen (PSA) level of less than 50 ng/mL, and a negative bone scan.

By 2017, 80% of the men enrolled in the study had died. Prostate cancer was the cause of death for 181 (32%) of these men, 71 in the surgical group and 110 in the watchful-waiting group. At 23 years of follow-up, the cumulative incidence of death from prostate cancer was 19.6% in the surgical group compared with 31.3% in the watchful-waiting group, and the mean number of years of life gained in the surgical group was 2.9 years. Among men who underwent prostatectomy, extracapsular extension and a Gleason score higher than 7 were strong predictors of death from prostate cancer.

The authors note that a limitation of this study is that diagnostic procedures today vary greatly from those used during this trial's enrollment period, during which the majority of the men had clinically detected, palpable tumors. Most men who are diagnosed with prostate cancer now have nonpalpable tumors detected by changes in PSA levels, the researchers point out, and undergo multiple biopsies or magnetic resonance imaging with targeted biopsies.

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