A Structured Literature Review of Treatment for Localized Prostate Cancer
John H. Wasson, MD;
Cynthia C. Cushman, MD;
Reginald C. Bruskewitz, MD;
Benjamin Littenberg, MD;
Albert G. Mulley, Jr, MD, MPP;
John E. Wennberg, MD, MPH
Arch Fam Med. 1993;2(5):487-493.
Abstract
Objective
We performed a structured literature review to define the clinical course of localized prostate cancer, the effectiveness of radical surgery and radiation therapy, and treatment complications.
Article Selection
We identified more than 1600 Englishlanguage, MEDLINE referenced articles for 1966 through 1991. All but 144 were excluded because they lacked primary data, involved fewer than 15 patients, or described neither the course of the disease nor treatment complications.
Data Synthesis
In these 144 articles, persistent genitourinary complications were more common after radical surgery than after external-beam radiation. Radiation resulted in a higher incidence of bowel problems. The median annual risks for the development of distant metastases and cancer-related death were 2.6% and 1.0%, respectively. Because tumor grade was correlated with metastases (Spearman correlation r=.56) and cancer mortality (r=.31), controlling for grade was necessary before we could compare the effectiveness of treatments for these outcomes. However, stratification by grade of malignancy was available in only nine of the patient series describing metastatic rates and in seven describing cancerrelated mortality. Furthermore, in the patient series that described prostate cancer—related metastatic rates, 48% neglected to identify patients unavailable for follow-up, 92% did not stratify patients by age, and only 48% stratified patients by the extent of disease at treatment.
Conclusions
Although we were able to compare complications of treatments, we were unable to determine treatment effectiveness for localized prostate cancer because of methodologic inadequacies in the literature we reviewed. Until better scientific evidence is available, patients and their physicians cannot make informed choices based on knowledge of the benefits of radical prostatectomy, radiation, or watchful waiting.
Author Affiliations
Prostate Disease Patient Outcome Research Team
From the Center for the Evaluative Clinical Sciences, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH (Drs Wasson and Wennberg), the Department of Pediatrics (Dr Cushman) and the Technology Assessment Program (Dr Littenberg), Dartmouth Hitchcock Medical Center, Lebanon, NH; the General Internal Medicine Unit of the Medical Services, Massachusetts General Hospital, Boston (Dr Mulley); and the Clinical Science Center, University of Wisconsin Medical School, Madison (Dr Bruskewitz). Dr Littenberg is an American College of Physicians George Morris Piersol teaching and research scholar.
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