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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 English-language, 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 cancer-related 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.
John H. Wasson (Sat,) studied this question.