To quote Dr. Leibowitz on the Swedish study:

"Of note is that men assigned to radical prostatectomy were treated on
relapse with immediate hormone blockade, while those on watchful waiting
had delayed therapy. Since many believe that early hormone blockade
improves survival, this would bias the study against watchful waiting. I
would point out that in the watchful waiting group, there were 21
Gleason 8-10's; only 14 in the radical prostatectomy group. There were
more Gleason 7's in watchful waiting arm than the radical prostatectomy
arm. Follow-up PSA results are not given. Obviously anyone with a rising
PSA after radical prostatectomy would be considered a failure, but these
results are not given. The authors also stressed that their results were
obtained primarily in a group of men with clinically-detected prostate
cancer, rather than the much more commonly PSA-detected prostate cancer
that we now have. Only 10% of their patients were PSA-detected. In fact,
one of their conclusions is that in men with cancer detected by PSA
screening, the baseline risk of death from prostate cancer may be even
lower since men survive years longer the earlier you diagnose their
prostate cancer. If you only diagnose the disease when it has spread to
the bones, survival is much shorter than PSA-detected cases. This means
that for the first five to eight years after PSA-detected cases, most
men will not die from prostate cancer, even without treatment. Any
possible benefit from surgery would not be apparent for several more
years. Thus, the absolute benefit of radical treatment, if any, may be
even less pronounced for patients diagnosed by PSA screening (the way
prostate cancer is usually diagnosed today in the USA) than the way men
were diagnosed in this study."

From the above, I gather that RP patients were treated more
aggressively (and sooner) to keep them alive, whereas WW patients were
let go too long (bone mets) before starting treatment.

Also, if surgery removes 99.999% or so of the existing prostate
cancer(PCa) cells, then even if the remaining cells are growing at a
faster rate, it is still possible for WW patients to die sooner since
they have so many more PCa cells to start with.  The other point is that
some men will be cured by the surgery, so that no one in their right
mind would advocate WW over RP if they are interested in long term
survival rates from PCa.  The only reason to suggest WW over RP is if
the patient is unlikely to live that much longer anyway (I think 10
years or less is the number usually given).

If you check over past postings to the alt.support.cancer.prostate
newsgroup, you will see an occassional posting with a very sad
description of men who had RP, then had their PSA skyrocket upwards
shortly afterwards at a velocity much higher than they had prior to
surgery.  These would be those men unfortunate enough to have had
substantial numbers of cells outside of their prostate at the time of
their surgery.  If you deny that surgery speeds the doubling time of
surviving prostate cancer cells, then how do you explain those cases?

Ed Friedman

Alan,

The explanation you are looking for is the angiogenesis theory, which to
put simply states that the primary tumor mass releases chemicals which
inhibit the growth of any metastases that exist.  When the primary tumor
mass is eliminated, the inhibition stops and metastases grow more rapidly.

Check out the paper "Excisional Therapy for cancer cure: therapy at a
cost" in The Lancet Oncology, Vol. 4, Dec. 2003:760-768.

Another way to think of this is to ask yourself the question - who has
longer to live, the man with a PSA of 8 with prostate cancer and no
localized treatment or the man who has RP then has his PSA go up to 8?

Ed Friedman