The results of a study published in the New England Journal of Medicine showed that surgery for early-stage prostate cancer was no better in saving lives than observation alone over a 10-year period. The study compared radical prostatectomy with watchful waiting in men diagnosed with low-grade localized prostate cancer and concluded that surgery did not significantly prolong the lives of many of the men.
Because prostatic surgery for cancer can produce negative side effects, such as erectile dysfunction and loss of bladder control, determining which men diagnosed with prostate cancer stand to benefit in terms of survival is of critical importance. This new information, if embraced by patients and doctors, may radically change prostate cancer management in the United States, where the majority of early-stage prostate cancers are treated aggressively with surgery or radiation therapy.
As a urologist who treats prostate cancer on an ongoing basis, I have several concerns about the conclusions of this study. First, the average age of the men in this study was 67 years old. It is well known that prostate cancer in older men is far less aggressive than prostate cancer found in men in their 40s and 50s. Second, only about a third of the patients in the study were African American, who have an increased risk of prostate cancer and are often underrepresented in prostate cancer studies.
Third, the study does not address the treatment options for more aggressive cancers or for cancers in men in their 40s, 50s, and early 60s. Any urologic oncologist knows that aggressive treatment in this subset of patients saves lives.
In this study, the early aggressive surgical treatment of prostate cancer was prompted by elevated levels of prostate-specific antigen (PSA). There is no doubt that the reliance of PSA screening, in the years since its introduction, has led to overtreatment of prostate cancer.
PSA screening still remains the best marker for the early diagnosis of prostate cancer, but this study prompts us to look at older patients and treat them less aggressively than younger patients. Even in early-stage prostate cancer, watchful waiting or active surveillance becomes more attractive.
Certainly, this study is an eye-opener and encourages less aggressive treatment in a select group of prostate cancer patients. Urologists have known for some time that some men will do just as well in terms of survival without treatment for their prostate cancer. However, considerable controversy still exists over exactly which of these men can safely opt for no treatment.
Dr. Jonathan Simons, president and CEO of the Prostate Cancer Foundation, said that the foundation is investing in research and development of indicators that could better categorize patients and give urologists and patients a precise plan for curative surgery or radiation and avoidance of over-treating a less aggressive tumor. Unfortunately, these markers are not yet available. Dr. Simons said, “We are tracking with great interest new biomarkers in blood and urine that define which men need surgery that will be curative and which men can safely opt for watchful waiting programs or active surveillance.”
Whether a patient chooses to aggressively treat prostate cancer or take a more conservative approach is a matter that needs to be fairly evaluated by both patient and physician. The final word on the subject has not yet been written. The present study should not be construed as a blanket condemnation of aggressive treatment. Aggressive treatment is still appropriate in certain patients, but at the same time, the number of patients over 65 with low-grade localized prostate cancer who are treated conservatively is growing.
Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).
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