SOME of the most exciting news in prostate cancer treatment has come from Scandinavia, where so many men die of this disease. A groundbreaking study, conducted by the Scandinavian Cancer Group and published in the September 12, 2002, issue of the New England Journal of Medicine, provides the first concrete evidence that treating localized disease reduces deaths from prostate cancer.

In the study, involving hospitals from Sweden, Finland, and Iceland, nearly 700 men with localized prostate cancer were randomly assigned to radical prostatectomy or to watchful waiting, the most common form of treatment in those countries. During the average follow-up of six years— a surprisingly short time—twice as many men in the watchful waiting group died of prostate cancer. This means, the scientists concluded, that radical prostatectomy may reduce prostate cancer deaths by about half.

A man’s risk of dying from prostate cancer exists for 20 to 25 years after he is diagnosed. In another study from Sweden, 63 percent of men who were treated with watchful waiting, who lived longer than 10 years, eventually died of prostate cancer. In the Scandinavian study, at 8 years, there was an absolute reduction of 14 percent in the number of men whose cancer had progressed to distant metastases (27 percent of men in the watchful waiting group developed metastases, compared to 13 percent in the surgery group). The scientists, noting that the average survival of men with distant metastases is only about two to three years, anticipate that with longer follow-up, the differences in cancer deaths between these two groups will become even more distinct.

What about quality of life? The men who had surgery experienced more erectile dysfunction and urinary leakage, and less urinary obstruction than the men in the watchful waiting group. However, in the Scandinavian trial, nerve-sparing surgery was not routinely performed. Also, many men in the trial were over age 65, and thus more likely to experience problems with incontinence and impotence. And 20 percent of these men had received hormonal therapy within five years after being diagnosed with cancer.

Any of these three factors—the lack of a standardized, nerve-sparing procedure, older age, and the use of hormonal therapy —could explain why there were more complications with radical prostatectomy in this study than if the operation had been performed uniformly, at a center where many of these procedures are done each year.