The Swedish Prostate Cancer Paradox

In this issue ofTHE JOURNAL, investigators from Sweden present their 15-year results of expectant management of prostate cancer.1They conclude that localized prostate cancer has a favorable outlook following watchful waiting and that the number of deaths potentially avoidable by initial radical treatment is limited. These results sound encouraging and suggest that the aggressive approach to early diagnosis and therapy currently used by many physicians in the United States may constitute overtreatment. However, prostate cancer is far from being a benign disease in Sweden. Sweden has the fourth-highest age-adjusted mortality rate from prostate cancer in the world, 21% higher than the United States, which ranks 13th.2This article thus presents a conundrum: if watchful waiting in localized disease results in few deaths, why is the overall mortality from prostate cancer in Sweden high? See also p 467. In the 223 cases of localized prostate cancer managed with