Quality of Life after Radical Prostatectomy or Watchful Waiting
Gunnar Steineck, M.D., Fred Helgesen, M.D., Jan Adolfsson, M.D., Paul W. Dickman, Ph.D., Jan-Erik Johansson, M.D., Bo Johan Norlén, M.D., Lars Holmberg, M.D., for the Scandinavian Prostatic Cancer Group Study Number 4
Background We evaluated symptoms and self-assessments of qualityof life in men with localized prostate cancer who participatedin a randomized comparison between radical prostatectomy andwatchful waiting.
Methods Between 1989 and 1999, a group of Swedish urologistsrandomly assigned men with localized prostate cancer to radicalprostatectomy or watchful waiting. In this follow-up study,we obtained information from 326 of 376 eligible men (87 percent)concerning certain symptoms, symptom-induced distress, well-being,and the subjective assessment of quality of life by means ofa mailed questionnaire.
Conclusions The assignment of patients to watchful waiting orradical prostatectomy entails different risks of erectile dysfunction,urinary leakage, and urinary obstruction, but on average, thechoice has little if any influence on well-being or the subjectivequality of life after a mean follow-up of four years.
A man with newly diagnosed localized prostate cancer faces afrustrating choice of therapy.1 He can defer treatment untilsymptoms appear (watchful waiting), undergo major surgery (radicalprostatectomy), or receive radiotherapy (interstitial or external)with the intention of eliminating the tumor.2,3 He may alsoreceive hormonal therapy with antiandrogens or undergo castration.His choice may influence survival as well as the risk of therapy-inducedacute or chronic symptoms.4
Between 1989 and 1999, a group of Swedish urologists enrolledmen with localized high-grade or moderate-grade prostate cancerin a randomized trial to compare radical prostatectomy withwatchful waiting.5 We examined the sexual, urinary, and bowelfunction and certain aspects of the quality of life in thesetwo groups of men.
Methods
We attempted to include all 376 men with localized prostatecancer who were enrolled in the Scandinavian Prostatic CancerGroup Study Number 45 between January 1, 1989, and February29, 1996 (men from Finland and those enrolled at a later datewere excluded). For this study, data were collected at least12 months after surgery and 14 months after randomization (during1997 and the beginning of 1998). Men younger than 75 years ofage and with a life expectancy of more than 10 years (as judgedby the attending physician) were included in the trial. Menwith a previously diagnosed cancer, a concurrent disorder consideredto increase the risk of operative mortality, or an inabilityto comply with treatment and follow-up were excluded. Men withuntreated tumors classified as localized (T0d, T1, or T2 accordingto the 1978 criteria6 or, beginning in 1994, T1c according tothe 1992 criteria7 of the International Union against Cancer)and of grade 1 or 2 according to the criteria of the World HealthOrganization,8 on the basis of a core-biopsy or a needle-aspiration–biopsyspecimen, were eligible. A negative bone scan and a prostate-specificantigen level of less than 50 ng per milliliter were requiredfor inclusion, and patients had to be randomly assigned withinfour months after the date of diagnosis. Men assigned to surgerywere advised to undergo a radical prostatectomy. The surgicalprocedure started with examination of regional lymph nodes,and only when these nodes were tumor-free was the prostate glandexcised (according to the Walsh–Lepor technique).9 Excisionof all tumor was given priority over the preservation of potency.Watchful waiting implied that no advice for initial radicaltherapy was given.
Urologists followed patients in both groups regularly (everysix months for two years and then annually) with a physicalexamination, a digital rectal examination of the prostate gland,and measurements of the prostate-specific antigen level. Bonescintigraphs were obtained annually. Patients with symptomsor signs of local progression or metastatic disease underwentfurther diagnostic studies, as clinically indicated. The studywas approved by the appropriate ethics committees.
After an introductory letter and contact by telephone, patientswho agreed to participate in this study were mailed a questionnaire,which was developed on the basis of interviews with patients,tested for face validity on 30 men (an investigator accompaniedthese men when they filled out the questionnaire, observingwhether or not the questions were understood correctly), andexamined in a small pilot study. It was based on and to a largeextent identical with instruments previously used10,11,12,13and comprised 77 questions and two psychometric scales (Spielberger'sTrait measure from the State–Trait Anxiety Inventory14and the Center for Epidemiological Studies Measure of Depression15).
We asked about the quality, frequency, and intensity of a symptomwhen appropriate. For example, the question "How often do youleak urine between voidings?" had the following possible answers:"Not relevant — I do not leak urine between voidings,""Less than once a week," "Approximately once a week," "Approximatelytwo to three times per week," "Approximately four to six timesper week," and "Seven times per week or more." The methods havebeen described in detail elsewhere.16
For seven symptoms, the corresponding distress was assessedaccording to a verbal scale of intensity. For example, the question"If you were to experience urinary leakage exactly as it isnow for the rest of your life, how would you feel about it?"had the following possible answers: "Not relevant — Ihave no urinary leakage," "It would not distress me at all,""It would distress me a little," "It would distress me moderately,"and "It would distress me a lot." We also asked three summaryquestions, the answers to which documented distress from compromisedsexual function, all urinary symptoms, and all bowel symptoms,respectively.
Psychological symptoms, well-being, and the subjective qualityof life (for the previous 14 days) were assessed on seven-pointvisual digital scales. The men marked one of seven numbers ona line anchored by, for example, no psychological well-beingand the best possible psychological well-being. Informationwas also collected on potential confounding and effect-modifyingfactors, such as concurrent diseases and treatments, includingcastration and transurethral resection of the prostate.
The analyses were performed according to the intention-to-treatprinciple and according to the treatment received. Outcome variableswere dichotomized (most cutoff values have been used previously10,11,12),and the results are presented as relative risks, calculatedas the percentage of men randomly assigned to radical prostatectomywith a specific outcome divided by the percentage of men randomlyassigned to watchful waiting with the same specific outcome.Estimated relative risks and associated 95 percent confidenceintervals were adjusted for background factors by the Mantel–Haenszelmethod.17,18
Results
Questionnaires were returned by 166 of the 189 men assignedto radical prostatectomy (88 percent) and 160 of the 187 menassigned to watchful waiting (86 percent). For each specificquestion, a few men did not respond. The average age at randomizationwas 64.1 years in men assigned to radical prostatectomy and64.8 years in men assigned to watchful waiting (Table 1). Theage range for all men was 48 to 74 years. The average age atthe time the questionnaire was completed was somewhat higherin the watchful-waiting group, and the time from randomizationto providing information on the questionnaire was, on average,1.5 months shorter.
Table 1. Characteristics of the Patient Population.
Among those assigned to radical prostatectomy who participatedin this follow-up, 80 percent actually had the gland removed;the remainder, in most cases, had tumor growth in the lymphnodes. In the watchful-waiting group, 6 percent ultimately hada radical prostatectomy. Time from randomization to surgerywas, on average, nearly a year longer in the watchful-waitinggroup. Adjustment for age, time from randomization to completionof the questionnaire, date of responding to the questionnaire,and educational level had little if any effect on the relativerisks. Relative risks were similar when analyses were basedon treatment received as opposed to intention to treat. Unadjustedintention-to-treat values are reported here.
Sexual Function
The frequency of sexual thoughts was similar in the two groups(Table 2). The prevalence of satisfactory erectile functionwas higher in the watchful-waiting group for the three questionsasked (regarding voluntary erection in sexual situations, erectionon awakening, and spontaneous erections). When the answers werecombined, 45 percent in the watchful-waiting group reportederectile dysfunction as compared with 80 percent in the radical-prostatectomygroup. Among men in the radical-prostatectomy group who wereable to obtain an erection, it was more often insufficientlymaintained. Pleasure, if orgasm occurred, was similar in thetwo groups, as was pain during intercourse. Altogether, 32 ofthe men assigned to radical prostatectomy had intercourse oncea month or more often, and 61 men had had an orgasm during theprevious six months (many of these men were classified as havingerectile dysfunction). Most men who had noticed the volume ofthe ejaculate reported it to be decreased. Somewhat fewer menin the prostatectomy group reported their sexual function tobe important than in the watchful-waiting group (the confidenceinterval included 1.0). Among men assigned to radical prostatectomy,56 percent were distressed (moderately or greatly) by a declinein sexual function, as compared with 40 percent of men assignedto watchful waiting.
Table 2. Occurrence and Intensity of Symptoms and Distress Associated with Sexual Dysfunction, According to the Intention to Treat.
Urinary Function
The five symptoms indicating a compromised emptying capacityof the urinary bladder (urinary obstruction) and the two symptomsindicating a limited storing capacity showed a decreased prevalenceamong those assigned to radical prostatectomy (Table 3). A weakurinary stream was reported by 28 percent of men assigned toradical prostatectomy and 44 percent of men assigned to watchfulwaiting. The values for emptying difficulties, as assessed byan American Urological Association symptom index score of 8to 35 points, were 35 percent in the radical-prostatectomy groupand 49 percent in the watchful-waiting group.
Table 3. Occurrence and Intensity of Symptoms and Distress Associated with Dysfunction of the Urinary Tract, According to the Intention to Treat.
By contrast, all variables related to urinary leakage had ahigher prevalence among those assigned to radical prostatectomy.Almost half the men in the radical-prostatectomy group had urinaryleakage at least once a week; 18 percent of the men assignedto radical prostatectomy and 2 percent of the men assigned towatchful waiting reported a moderate or severe degree of urinaryleakage. Twenty-seven percent of the men assigned to radicalprostatectomy and 18 percent of the men assigned to watchfulwaiting stated that they were moderately or greatly distressedby urinary problems (obstruction and leakage).
Bowel Function
The values for variables related to bowel function for radicalprostatectomy and watchful waiting, respectively, were as follows:15 of 165 (9 percent) and 14 of 165 (8 percent) for constipation,11 of 163 (7 percent) and 10 of 154 (6 percent) for defecationurgency, 2 of 165 (1 percent) and 1 of 157 (1 percent) for bloodor mucus in the stool, 13 of 164 (8 percent) and 8 of 158 (5percent) for diarrhea, 1 of 164 (1 percent) and 9 of 157 (6percent) for fecal leakage once a week or more, and 11 of 164(7 percent) and 16 of 156 (10 percent) for some fecal leakage.Moderate or great distress from fecal leakage was reported by3 of 164 men assigned to radical prostatectomy (2 percent) and7 of 155 men assigned to watchful waiting (5 percent). The valuesfor distress from all bowel symptoms were 5 of 159 for the radical-prostatectomygroup (3 percent) and 10 of 156 for the watchful-waiting group(6 percent).
Psychological Symptoms
All nine psychological variables presented in Table 4 had alower prevalence among men assigned to radical prostatectomythan among those assigned to watchful waiting, but all confidenceintervals for the relative risks include 1.0. Low or moderatepsychological well-being was reported by 35 percent of men assignedto radical prostatectomy and 36 percent of men assigned to watchfulwaiting. The values for low or moderate subjective quality oflife were 40 percent in the radical-prostatectomy group and45 percent in the watchful-waiting group.
From studies before and after surgery, we know that radicalprostatectomy can cause erectile dysfunction.19,20 The prevalenceof associated erectile dysfunction, its relation to the skillof the surgeon and procedures used, and the extent to whichit induces distress remain uncertain. The prevalence of erectiledysfunction we observed among the men assigned to watchful waitingin our study (45 percent) is higher than the 32 percent observedamong population controls of the same age in a previous Swedishstudy.21 This difference suggests that a growing tumor (or castrationas treatment for such a tumor) may cause erectile dysfunctionin men who choose watchful waiting. The alternative treatments,radiotherapy and hormonal therapy, may also cause erectile dysfunction.5Consequently, for a man evaluating treatment strategies forlocalized prostate cancer, all the alternative approaches canjeopardize his potency, although they do so with varying frequency.
Age, concurrent diseases, and hormonal therapy (including castration)may influence the prevalence of erectile dysfunction,24,25 andthe values observed in a specific population depend on the wordingof the question used and the cutoff value for preserved function.Asking separate questions about spontaneous, morning, and activity-relatederections, as we did, somewhat increases the sensitivity ofthe questionnaire for detecting true erectile function, as comparedwith one question only.26
Many men in this study reported having intercourse despite erectiledysfunction, possibly indicating successful pharmacologic treatmentfor impotence.27,28 Our data indicate that erectile functionis not the only determinant of an active sex life.
Previous studies showed that urinary leakage is an unwantedchronic effect of radical prostatectomy,29,30,31,32 but publishedvalues on urinary incontinence vary depending on patient selection,the definition of incontinence, and the method of data collection.In one national sample from the United States,31 incontinencerequiring the use of pads was found in 39 percent of men aftera perineal prostatectomy and 56 percent of men after a retropubicprostatectomy (we found it in 43 percent of men after radicalprostatectomy). In a study from the National Cancer Institutein men who had undergone radical prostatectomy,33 urinary incontinencewas found in only 10 percent when defined as "no control orfrequent leaks or drips of urine" but in 28 percent when definedas a need to "wear pads to stay dry." We found urinary leakageonce a week or more often among 21 percent of the men in thewatchful-waiting group. If instead only some leakage was considered,the proportion was 35 percent. The numbers are higher than thoseobtained for population controls in Sweden,34 indicating aneffect of the unremoved tumor. Thus, an excess risk of urinaryleakage occurs both after radical prostatectomy and during watchfulwaiting, but the magnitude of the risk associated with thesetwo choices differs.
The proportion of men reporting moderate or great distress dueto urinary leakage, when the symptom occurred, was somewhathigher in this series than in a previous population-based studyin Sweden.34 A large leakage distresses most men who experienceit.
We found no indication, as previously suggested,31,34 that radicalprostatectomy induces disturbances of defecation or symptomsof bowel dysfunction. Radiotherapy is undoubtedly associatedwith a risk of such problems33 and may be the only treatmentalternative for localized prostate cancer with this disadvantage.
Psychological symptoms, well-being, and the subjective qualityof life are correlated variables. For all such variables thatwe assessed the prevalence was lower in one group, but the observationswere not independent, and the confidence intervals for relativerisks include 1.0. Thus, the data are consistent with no differencebetween the two groups in this area.
In this randomized study, factors other than radical prostatectomyor leaving the tumor in situ that predict a specific outcomewere expected to be equally distributed between the groups.Lacking base-line data, we cannot assert that this is true forall symptoms we studied. An intention-to-treat analysis maintainsthe random allocation of such background factors but is confoundedby deviations from the planned treatment. The effects we interprethere as real were also apparent when we analyzed data accordingto treatment received. The high rate of participation (87 percent)indicates minor problems due to selection. To resemble "blinding"and avoid investigator-related bias, the questionnaire was filledout by the men at home and sent to an address not related topast and future care, thus increasing the likelihood that errorsin measurement were similar in the two groups, which tends toreduce observed differences in risk. The wording of our questionsasking for symptom-induced distress — indicating thatthe specific symptom would persist for the rest of the man'slife — may have diminished variability due to variationsin the perceived duration of symptoms. Face validation ensuredthat our instrument assessed what we aimed to measure, the men'ssubjective perception of abnormal function. We probably lostsome statistical power by dichotomizing the outcome. Adjustmentsfor background factors may or may not increase validity.35 Wehave presented unadjusted relative risks, but the figures changedlittle, if at all, after adjustment.
Erectile dysfunction and urinary leakage are important sourcesof decreased well-being after radical prostatectomy, whereasobstructed voiding is an important source after watchful waiting.The distress induced by a specific symptom varies considerablyamong patients. Moreover, some men give full priority to survival— even when the gain is small — whereas others wantto avoid therapy-induced distressful symptoms, even when facedwith certain decreased prospects of survival.12
For all these reasons, we cannot say that radical prostatectomyis better than watchful waiting for all men with localized prostatecancer. These alternatives are associated with complex and incommensurableoutcomes, and each man must judge for himself which treatmentis preferable.
Supported by the Swedish Cancer Society and King Gustav V'sJubilee Fund.
Source Information
From the Department of Oncology and Pathology (G.S., F.H., P.W.D.) and the Department of Medical Epidemiology (P.W.D.), Karolinska Institutet, Stockholm; the Department of Urology and the Center for Assessment of Medical Technology, University Hospital, Örebro (F.H., J.-E.J.); Center for Surgical Sciences, Karolinska Institutet and Oncologic Center, Stockholm (J.A.); and the Department of Urology (B.J.N.) and the Department of Surgery, Regional Oncology Center (L.H.), University Hospital, Uppsala — all in Sweden.
Address reprint requests to Dr. Steineck at Clinical Cancer Epidemiology, Radiumhemmet, Karolinska Institutet, 17176 Stockholm, Sweden, or at gunnar.steineck{at}onkpat.ki.se.
References
Barry MJ. Prostate-specific-antigen testing for early diagnosis of prostate cancer. N Engl J Med 2001;344:1373-1377. [Free Full Text]
Fowler FJ Jr, McNaughton Collins M, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. JAMA 2000;283:3217-3222. [Free Full Text]
Thompson IM. Counseling patients with newly diagnosed prostate cancer. Oncology (Huntingt) 2000;14:119-26, 131. [Medline]
Barry MJ, Albertsen PC, Bagshaw MA, et al. Outcomes for men with clinically nonmetastatic prostate carcinoma managed with radical prostatectomy, external beam radiotherapy, or expectant management: a retrospective analysis. Cancer 2001;91:2302-2314. [CrossRef][Web of Science][Medline]
Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med 2002;347:781-789. [Free Full Text]
Harmer MH, ed. TNM classification of malignant tumors. 3rd ed. rev. Geneva: International Union against Cancer, 1982.
Murphy GP, Busch C, Abrahamsson PA, et al. Histopathology of localized prostate cancer: Consensus Conference on Diagnosis and Prognostic Parameters in Localized Prostate Cancer, Stockholm, Sweden, May 12-13, 1993. Scand J Urol Nephrol Suppl 1994;162:7-42. [Medline]
Walsh PC, Lepor H, Eggleston JC. Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate 1983;4:473-485. [Web of Science][Medline]
Henningsohn L, Steven K, Kallestrup EB, Steineck G. Distressful symptoms and well-being after radical cystectomy and orthotopic bladder substitution compared with a matched control population. J Urol 2002;168:168-174. [Medline]
Bergmark K, Avall-Lundqvist E, Dickman PW, Henningsohn L, Steineck G. Vaginal changes and sexuality in women with a history of cervical cancer. N Engl J Med 1999;340:1383-1389. [Free Full Text]
Helgason AR, Adolfsson J, Dickman P, Fredrikson M, Arver S, Steineck G. Waning sexual function -- the most important disease-specific distress for patients with prostate cancer. Br J Cancer 1996;73:1417-1421. [Web of Science][Medline]
Borjeson S, Hursti TJ, Peterson C, et al. Similarities and differences in assessing nausea on a verbal category scale and a visual analogue scale. Cancer Nurs 1997;20:260-266. [CrossRef][Web of Science][Medline]
Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psych Meas 1994;1:385-401.
Steineck G, Bergmark K, Henningsohn L, al-Abany M, Dickman PW, Helgason AR. Symptom documentation in cancer survivors as a basis for therapy modifications. Acta Oncol 2002;41:244-252. [CrossRef][Web of Science][Medline]
Rothman KJ, Greenland S. Modern epidemiology. 2nd ed. Philadelphia: Lippincott–Raven, 1998.
SAS procedure guide, version 6. 3rd ed. Cary, N.C.: SAS Institute, 1990.
Stanford JL, Feng Z, Hamilton AS, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 2000;283:354-360. [Free Full Text]
Litwin MS, Flanders SC, Pasta DJ, Stoddard ML, Lubeck DP, Henning JM. Sexual function and bother after radical prostatectomy or radiation for prostate cancer: multivariate quality-of-life analysis from CaPSURE: Cancer of the Prostate Strategic Urologic Research Endeavor. Urology 1999;54:503-508. [CrossRef][Web of Science][Medline]
Helgason AR, Adolfsson J, Dickman P, et al. Sexual desire, erection, orgasm and ejaculatory functions and their importance to elderly Swedish men: a population-based study. Age Ageing 1996;25:285-291. [Free Full Text]
Walsh PC. Radical prostatectomy for localized prostate cancer provides durable cancer control with excellent quality of life: a structured debate. J Urol 2000;163:1802-1807. [CrossRef][Web of Science][Medline]
Walsh PC. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol 1998;160:2418-2424. [CrossRef][Web of Science][Medline]
Helgason AR, Adolfsson J, Dickman P, Arver S, Fredrikson M, Steineck G. Factors associated with waning sexual function among elderly men and prostate cancer patients. J Urol 1997;158:155-159. [CrossRef][Web of Science][Medline]
Lue TF. Erectile dysfunction. N Engl J Med 2000;342:1802-1813. [Free Full Text]
Helgason AR, Arver S, Adolfsson J, Dickman P, Granath F, Steineck G. `Potency': the validation of information from a self-administered questionnaire using objective measurements of night-time erections and test-retest reliability. Br J Urol 1998;81:135-141. [Medline]
Feng MI, Huang S, Kaptein J, Kaswick J, Aboseif S. Effect of sildenafil citrate on post-radical prostatectomy erectile dysfunction. J Urol 2000;164:1935-1938. [CrossRef][Medline]
McMahon CG, Samali R, Johnson H. Efficacy, safety and patient acceptance of sildenafil citrate as treatment for erectile dysfunction. J Urol 2000;164:1192-1196. [CrossRef][Medline]
Fontaine E, Izadifar V, Barthelemy Y, Desgrippes A, Beurton D. Urinary continence following radical prostatectomy assessed by a self-administered questionnaire. Eur Urol 2000;37:223-227. [Medline]
Potosky AL, Harlan LC, Stanford JL, et al. Prostate cancer practice patterns and quality of life: the Prostate Cancer Outcomes Study. J Natl Cancer Inst 1999;91:1719-1724. [Free Full Text]
Bishoff JT, Motley G, Optenberg SA, et al. Incidence of fecal and urinary incontinence following radical perineal and retropubic prostatectomy in a national population. J Urol 1998;160:454-458. [CrossRef][Web of Science][Medline]
Fowler FJ Jr, Barry MJ, Lu-Yao G, Wasson J, Roman A, Wennberg J. Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a Medicare survey. Urology 1995;45:1007-1013. [CrossRef][Web of Science][Medline]
Potosky AL, Legler J, Albertsen PC, et al. Health outcomes after prostatectomy or radiotherapy for prostate cancer: results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst 2000;92:1582-1592. [Free Full Text]
Adolfsson J, Helgason AR, Dickman P, Steineck G. Urinary and bowel symptoms in men with and without prostate cancer: results from an observational study in the Stockholm area. Eur Urol 1998;33:11-16. [Medline]
Greenland S. Modeling and variable selection in epidemiologic analysis. Am J Public Health 1989;79:340-349. [Free Full Text]
Adolfsson J, Steineck G, Whitmore WF Jr. Recent results of management of palpable clinically localized prostate cancer. Cancer 1993;72:310-322. [CrossRef][Web of Science][Medline]
Prostatectomy or Watchful Waiting in Prostate Cancer
Blanker M. H., Bierma-Zeinstra S. M.A., Schouten B. W.V., Coen J. J., Zietman A. L., Shipley W. U., Gambacorti-Passerini C. B., Sala E. A., Sonpavde G., Stern S. D., Bill-Axelson A., Holmberg L.
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Correspondence
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1: 18-28
[Abstract]
Wong, Y.-N., Mitra, N., Hudes, G., Localio, R., Schwartz, J. S., Wan, F., Montagnet, C., Armstrong, K.
(2006). Survival Associated With Treatment vs Observation of Localized Prostate Cancer in Elderly Men. JAMA
296: 2683-2693
[Abstract][Full Text]
Albertsen, P. C.
(2006). PSA Testing: Public Policy or Private Penchant?. JAMA
296: 2371-2373
[Full Text]
Smellie, W S A, Forth, J, Sundar, S, Kalu, E, McNulty, C A M, Sherriff, E, Watson, I D, Croucher, C, Reynolds, T M, Carey, P J
(2006). Best practice in primary care pathology: review 4. J. Clin. Pathol.
59: 893-902
[Abstract][Full Text]
Miller, D. C., Gruber, S. B., Hollenbeck, B. K., Montie, J. E., Wei, J. T.
(2006). Incidence of initial local therapy among men with lower-risk prostate cancer in the United States.. JNCI J Natl Cancer Inst
98: 1134-1141
[Abstract][Full Text]
Blazeby, J. M., Avery, K., Sprangers, M., Pikhart, H., Fayers, P., Donovan, J.
(2006). Health-Related Quality of Life Measurement in Randomized Clinical Trials in Surgical Oncology. JCO
24: 3178-3186
[Abstract][Full Text]
Ribeiro, F. R., Jeronimo, C., Henrique, R., Fonseca, D., Oliveira, J., Lothe, R. A., Teixeira, M. R.
(2006). 8q Gain Is an Independent Predictor of Poor Survival in Diagnostic Needle Biopsies from Prostate Cancer Suspects.. Clin. Cancer Res.
12: 3961-3970
[Abstract][Full Text]
Gwede, C. K., McDermott, R. J.
(2006). Prostate Cancer Screening Decision Making Under Controversy: Implications for Health Promotion Practice. Health Promot Pract
7: 134-146
[Abstract]
Klotz, L.
(2005). Active Surveillance for Prostate Cancer: For Whom?. JCO
23: 8165-8169
[Abstract][Full Text]
Stuart, M. E., Strite, S. A., Marantz, P. R., Hall, C. B., Derby, C. A., Liss, H. K., Elmore, J. G., Sonpavde, G., Bill-Axelson, A., Holmberg, L., Johansson, J.-E.
(2005). Radical Prostatectomy versus Watchful Waiting. NEJM
353: 1298-1300
[Full Text]
Bradley, C. J., Neumark, D., Luo, Z., Bednarek, H., Schenk, M.
(2005). Employment Outcomes of Men Treated for Prostate Cancer. JNCI J Natl Cancer Inst
97: 958-965
[Abstract][Full Text]
Routh, J. C., Leibovich, B. C.
(2005). Adenocarcinoma of the Prostate: Epidemiological Trends, Screening, Diagnosis, and Surgical Management of Localized Disease. Mayo Clin Proc.
80: 899-907
[Abstract]
Bill-Axelson, A., Holmberg, L., Ruutu, M., Haggman, M., Andersson, S.-O., Bratell, S., Spangberg, A., Busch, C., Nordling, S., Garmo, H., Palmgren, J., Adami, H.-O., Norlen, B. J., Johansson, J.-E., the Scandinavian Prostate Cancer Group Study No. 4,
(2005). Radical Prostatectomy versus Watchful Waiting in Early Prostate Cancer. NEJM
352: 1977-1984
[Abstract][Full Text]
Johnson, T. K., Gilliland, F. D., Hoffman, R. M., Deapen, D., Penson, D. F., Stanford, J. L., Albertsen, P. C., Hamilton, A. S.
(2004). Racial/Ethnic Differences in Functional Outcomes in the 5 Years After Diagnosis of Localized Prostate Cancer. JCO
22: 4193-4201
[Abstract][Full Text]
Kreicbergs, U., Valdimarsdottir, U., Onelov, E., Henter, J.-I., Steineck, G.
(2004). Talking about Death with Children Who Have Severe Malignant Disease. NEJM
351: 1175-1186
[Abstract][Full Text]
Potosky, A. L., Davis, W. W., Hoffman, R. M., Stanford, J. L., Stephenson, R. A., Penson, D. F., Harlan, L. C.
(2004). Five-Year Outcomes After Prostatectomy or Radiotherapy for Prostate Cancer: The Prostate Cancer Outcomes Study. JNCI J Natl Cancer Inst
96: 1358-1367
[Abstract][Full Text]
Paris, P. L., Andaya, A., Fridlyand, J., Jain, A. N., Weinberg, V., Kowbel, D., Brebner, J. H., Simko, J., Watson, J.E. V., Volik, S., Albertson, D. G., Pinkel, D., Alers, J. C., van der Kwast, T. H., Vissers, K. J., Schroder, F. H., Wildhagen, M. F., Febbo, P. G., Chinnaiyan, A. M., Pienta, K. J., Carroll, P. R., Rubin, M. A., Collins, C., van Dekken, H.
(2004). Whole genome scanning identifies genotypes associated with recurrence and metastasis in prostate tumors. Hum Mol Genet
13: 1303-1313
[Abstract][Full Text]
Johansson, J.-E., Andren, O., Andersson, S.-O., Dickman, P. W., Holmberg, L., Magnuson, A., Adami, H.-O.
(2004). Natural History of Early, Localized Prostate Cancer. JAMA
291: 2713-2719
[Abstract][Full Text]
Neugut, A. I., Grann, V. R.
(2004). Waiting Time in Prostate Cancer. JAMA
291: 2757-2758
[Full Text]
Kao, J, Turian, J, Meyers, A, Hamilton, R J, Smith, B, Vijayakumar, S, Jani, A B
(2004). Sparing of the penile bulb and proximal penile structures with intensity-modulated radiation therapy for prostate cancer. Br. J. Radiol.
77: 129-136
[Abstract][Full Text]
Bott, S R J, Birtle, A J, Taylor, C J, Kirby, R S
(2003). Prostate cancer management: (1) an update on localised disease. Postgrad. Med. J.
79: 575-580
[Abstract][Full Text]
Sheffield, J. V.L., Larson, E. B.
(2003). Update in General Internal Medicine. ANN INTERN MED
139: 285-293
[Full Text]
Sorum, P. C., Shim, J., Chasseigne, G., Bonnin-Scaon, S., Cogneau, J., Mullet, E.
(2003). Why do Primary Care Physicians in the United States and France Order Prostate-Specific Antigen Tests for Asymptomatic Patients?. Med Decis Making
23: 301-313
[Abstract]
Bottomley, A., Thomas, R., Van Steen, K., Flechtner, H., de Graeff, A.
(2003). Guidelines for the Use of Epoetin: Have Quality-of-Life Benefits Been Proven?. JCO
21: 2223-2223
[Full Text]
Wilt, T. J
(2003). Radical prostatectomy reduced death from prostate cancer but not all cause mortality. Evid. Based Med.
8: 41-41
[Full Text]
Jewett, M. A.S., Fleshner, N., Klotz, L. H., Nam, R. K., Trachtenberg, J.
(2003). Radical prostatectomy as treatment for prostate cancer. CMAJ
168: 44-45
[Full Text]
Siemens, D. R.
(2003). Radical prostatectomy or watchful waiting in early prostate cancer?. CMAJ
168: 67-67
[Full Text]
Kakehi, Y.
(2003). Watchful Waiting as a Treatment Option for Localized Prostate Cancer in the PSA Era. Jpn J Clin Oncol
33: 1-5
[Abstract][Full Text]
Smith, R. A., Cokkinides, V., Eyre, H. J.
(2003). American Cancer Society Guidelines for the Early Detection of Cancer, 2003. CA Cancer J Clin
53: 27-43
[Abstract][Full Text]
Harris, R., Lohr, K. N.
(2002). Screening for Prostate Cancer: An Update of the Evidence for the U.S. Preventive Services Task Force. ANN INTERN MED
137: 917-929
[Abstract][Full Text]
Chabner, B. A., Kaufman, D.
(2002). Pity the Poor Consumer. The Oncologist
7: 475-476
[Full Text]
(2002). Prostatectomy vs. Watchful Waiting in Early Prostate Cancer. JWatch General
2002: 1-1
[Full Text]
Holmberg, L., Bill-Axelson, A., Helgesen, F., Salo, J. O., Folmerz, P., Haggman, M., Andersson, S.-O., Spangberg, A., Busch, C., Nordling, S., Palmgren, J., Adami, H.-O., Johansson, J.-E., Norlen, B. J., the Scandinavian Prostatic Cancer Group Study Numb,
(2002). A Randomized Trial Comparing Radical Prostatectomy with Watchful Waiting in Early Prostate Cancer. NEJM
347: 781-789
[Abstract][Full Text]
Walsh, P. C.
(2002). Surgery and the Reduction of Mortality from Prostate Cancer. NEJM
347: 839-840
[Full Text]
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