Why is 6 afraid of 7?

Top Line: Sure, because seven ate nine. But Gleason 4+3=7 prostate cancer is scary in its own right.
The Study: Back in 1989, in the same month their neighbor Denmark became the first nation to legalize same-sex marriage, the Swedes tried their own hand at being progressive by initiating the SPCG-4 randomized trial of "watchful waiting" (i.e., without surveillance biopsies) versus standard radical prostatectomy for non-metastatic prostate cancer. In the decade that followed, it enrolled nearly 700 men with "clinically-localized" prostate cancer (i.e., per a negative bone scan) and a life expectancy of at least 10 years. These were pretty much all-comers with the only notable exclusion criteria being poorly-differentiated tumors and PSA ≥50—remember, it wasn’t until the turn of this century that Gleason score became a thing. And here we have long-term results with a median follow-up of over 23(!) years, at which point 80% of enrollees had died with one-third of deaths due to prostate cancer. Perhaps unsurprising among these all-comers, long-term survival rate was significantly improved with upfront radical prostatectomy: 28% versus 16% at 23 years, primarily due to a significantly lower rate of prostate cancer death (20% versus 31%). More interesting was that a post-hoc Gleason score of 4+3=7 was associated with over 5x the adjusted risk of prostate cancer death than a Gleason score of 6, with absolute rates of 30% versus 3%. P.S. It was only 5% for 3+4=7. And while race wasn’t described, we have a feeling this 90s accrual from Sweden, Finland and Iceland doesn’t do much to clear things up for our black patients.
Bottom Line: Long-term results support current guidelines that draw a line in the sand for offering active surveillance to (white) men with up to Gleason 3+4=7 prostate cancer. | Bill-Axelson, N Engl J Med 2018


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