Wasson J H, Cushman C C, Bruskewitz R C, Littenberg B, Mulley A G, Wennberg J E
Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH.
Arch Fam Med. 1993 May;2(5):487-93. doi: 10.1001/archfami.2.5.487.
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.
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.
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.
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.
我们进行了一项结构化文献综述，以明确局限性前列腺癌的临床病程、根治性手术和放射治疗的有效性以及治疗并发症。
我们在MEDLINE数据库中检索了1966年至1991年期间的1600多篇英文参考文献。除144篇外，其余均被排除，原因是它们缺乏原始数据、研究对象少于15例，或者既未描述疾病病程也未提及治疗并发症。
在这144篇文章中，根治性手术后持续性泌尿生殖系统并发症比体外放射治疗后更为常见。放射治疗导致肠道问题的发生率更高。远处转移和癌症相关死亡的年中位风险分别为2.6%和1.0%。由于肿瘤分级与转移（Spearman相关系数r = 0.56）和癌症死亡率（r = 0.31）相关，因此在比较这些结局的治疗效果之前，必须对分级进行控制。然而，在描述转移率的患者系列中，只有9个按恶性程度分级，在描述癌症相关死亡率的患者系列中，只有7个按恶性程度分级。此外，在描述前列腺癌相关转移率的患者系列中，48%未提及失访患者，92%未按年龄对患者进行分层，只有48%按治疗时疾病范围对患者进行分层。
尽管我们能够比较治疗的并发症，但由于我们所综述文献中的方法学缺陷，我们无法确定局限性前列腺癌的治疗效果。在获得更好的科学证据之前，患者及其医生无法基于对根治性前列腺切除术、放射治疗或观察等待的益处的了解做出明智的选择。
