Tumore della prostata. La chirurgia allunga la vita se i soggetti hanno meno di 65 anni

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Del tumore della prostata si è detto di tutto e di più: operarlo o non operarlo; quando operarlo e come operarlo. Una prima notizia di chiarezza arriva da alcuni ricercatori dell’Università di Uppsala, in Svezia, secondo i quali il beneficio della chirurgia è più evidente negli uomini di età inferiore ai 65 anni. In particolare, sembra che negli uomini con carcinoma prostatico localizzato la chirurgia prostatica radicale porti a un prolungamento della sopravvivenza di 3 anni rispetto a un approccio di monitoraggio attivo.

Per arrivare a queste conclusioni, i ricercatori coordinati dalla prof.ssa Anna Bill-Axelson hanno studiato 695 uomini in 14 centri distribuiti tra Svezia, Finlandia e Islanda. Nel corso dei controlli (follow-up) durati 29 anni, tra gli uomini sottoposti a chirurgia radicale si è verificato il 45% in meno di decessi dovuti al cancro della prostata. E all’interno di tutte le cause di morte, i decessi in questa coorte di pazienti rappresentavano il 72%, mentre tra coloro che non si erano sottoposti all’intervento di chirurgia radicale la percentuale saliva all’84%. Certamente un dato favore della chirurgia, specialmente quando c’è una lunga aspettativa di vita. Lo studio è stato pubblicato sulla rivista New England Journal of Medicine; di seguito ne pubblichiamo l’abstract.

ABSTRACT

N Engl J Med. 2018 Dec 13;379(24):2319-2329. doi: 10.1056/NEJMoa1807801.
Radical Prostatectomy or Watchful Waiting in Prostate Cancer – 29-Year Follow-up.
Bill-Axelson A, Holmberg L, Garmo H, Taari K, Busch C, Nordling S, Häggman M, Andersson SO, Andrén O, Steineck G, Adami HO, Johansson JE.

BACKGROUND

Radical prostatectomy reduces mortality among men with clinically detected localized prostate cancer, but evidence from randomized trials with long-term follow-up is sparse.

METHODS

We randomly assigned 695 men with localized prostate cancer to watchful waiting or radical prostatectomy from October 1989 through February 1999 and collected follow-up data through 2017. Cumulative incidence and relative risks with 95% confidence intervals for death from any cause, death from prostate cancer, and metastasis were estimated in intention-to-treat and per-protocol analyses, and numbers of years of life gained were estimated. We evaluated the prognostic value of histopathological measures with a Cox proportional-hazards model.

RESULTS

By December 31, 2017, a total of 261 of the 347 men in the radical-prostatectomy group and 292 of the 348 men in the watchful-waiting group had died; 71 deaths in the radical-prostatectomy group and 110 in the watchful-waiting group were due to prostate cancer (relative risk, 0.55; 95% confidence interval [CI], 0.41 to 0.74; P<0.001; absolute difference in risk, 11.7 percentage points; 95% CI, 5.2 to 18.2). The number needed to treat to avert one death from any cause was 8.4. At 23 years, a mean of 2.9 extra years of life were gained with radical prostatectomy. Among the men who underwent radical prostatectomy, extracapsular extension was associated with a risk of death from prostate cancer that was 5 times as high as that among men without extracapsular extension, and a Gleason score higher than 7 was associated with a risk that was 10 times as high as that with a score of 6 or lower (scores range from 2 to 10, with higher scores indicating more aggressive cancer).

CONCLUSIONS

Men with clinically detected, localized prostate cancer and a long life expectancy benefited from radical prostatectomy, with a mean of 2.9 years of life gained. A high Gleason score and the presence of extracapsular extension in the radical prostatectomy specimens were highly predictive of death from prostate cancer. (Funded by the Swedish Cancer Society and others.).