Prostate Surgery or Watchful Waiting: Which Is Better?

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Prostate Surgery or Watchful Waiting: Which Is Better?
Studies Give Clearer Picture of Two Options
Article date: 2005/05/11


Men who opt for prostate cancer surgery -- especially when they're under
age 65 -- are less likely to die of their disease than those who choose no
treatment, Scandinavian researchers report in this week's New England
Journal of Medicine.

The findings come on the heels of a US study published last week in the
Journal of the American Medical Association that suggested some men can
safely skip treatment -- a strategy known as watchful waiting.

Though the conclusions may seem contradictory, experts say they actually
complement each other. The Scandinavian study compared two treatment
options -- surgery or watchful waiting -- while the US study only looked
at how men fared once they'd already chosen watchful waiting. Both offer
information men can use when they make decisions about treatments.

"Any treatment decision is always based on many factors, including the age
of the patient, the other medical conditions a patient may have, and what
his life expectancy is," said Len Lichtenfeld, MD, deputy chief medical
director of the American Cancer Society. "It's important to have a
discussion with a doctor knowledgeable about prostate cancer before making
a decision."
Treatment Decisions Complex

Prostate cancer is the most common cancer in US men, after skin cancer.
This year alone, it is expected to strike more than 230,000 men, and kill
around 30,000. Treatments for early-stage disease include surgery,
radiation, or watchful waiting. But figuring out which treatment to choose
can be difficult, especially for men with early-stage disease.

That's because some prostate cancers grow very slowly and never cause
problems. Treating these cancers might not be necessary, and it could also
lead to unwelcome side effects like impotence and incontinence.

Other prostate cancers, though, are aggressive and deadly. For men with
these types of cancers, the benefits of treatment outweigh the risks of
its side effects.

There's no ironclad way to tell for certain which type of cancer a man
has, but there are some biological clues like PSA (prostate-specific
antigen) levels and Gleason score (a measure of how abnormal -- and
potentially aggressive -- the cancer cells are). Men with low marks in
both these categories may have slow-growing cancers, and may be candidates
for watchful waiting.

Last week's JAMA study, led by researchers at the University of
Connecticut Health Center, showed that men with very low Gleason scores --
between 2 and 4 -- generally do well in the long term with watchful
waiting.

The researchers studied the medical records of 767 men between the ages of
55 and 74 who had early-stage disease. All had been diagnosed in the 1970s
and early 1980s and all had chosen watchful waiting instead of aggressive
treatment. Those with Gleason scores under 4 were found to have very
little risk of dying because of their prostate cancer, even 20 years after
diagnosis. By contrast, men with the highest Gleason scores -- between 8
and 10 -- had a high risk of dying from prostate cancer.

The finding doesn't surprise Durado Brooks, MD, director of prostate and
colorectal cancers for ACS.

Like many cancer doctors, Brooks already believed that men with high-grade
tumors are more likely to die no matter what treatment they get. And
conversely, those with low-grade tumors are less likely to die even if
they get no treatment. The two studies add support to that belief.

Surgery Improved Survival in Younger Men

The new Scandinavian study suggests, however, that certain men may be
better off choosing surgery.

Researchers from the Scandinavian Prostate Cancer Study Group No. 4
studied 695 men under age 75 with early-stage prostate cancer. Half were
randomly assigned to treatment with a surgery called radical
prostatectomy, while the rest were assigned to watchful waiting. They were
tracked for 10 years.

In that time, men who got surgery were less likely than men who had no
treatment to have their cancer progress locally (19% vs. 44%) or spread to
other parts of the body (15% vs. 25%). They were also less likely to die
from prostate cancer (10% vs. 15%), but this difference was primarily seen
among men under age 65.

Although the study didn't have the statistical power to say for certain
that surgery is better for younger men, the data are suggestive, Brooks
said.

"It is good to see a well-designed, decent-sized study that has long-range
follow up that supports the concept that in some situations, prostatectomy
can decrease the mortality and morbidity related to prostate cancer,
considering how much the surgery is being done in this country," he said.

Current Practice Likely to Remain Unchanged

The two studies are unlikely to change the way doctors advise their
patients about prostate cancer treatment, Brooks said.

"My suspicion is that there aren't a lot of men under 65 without [other
medical problems] who are advised to watch and wait," he said.
"Watch-and-wait men are usually those over 65 with [other medical
problems] and low Gleason scores."

The first author of the US study agreed.

"The older men are the ones for watchful waiting," said Peter C.
Albertsen, MD, MS, chief of urology at the University of Connecticut
Health Center. "Younger men with high-grade disease should definitely go
for [treatment]."

Older men with high-grade disease could also benefit from treatment, he
said, but those decisions must always be made on a case by case basis.

Neither study dealt with the side effects of each treatment option, nor
looked at men who chose radiation treatment for their prostate cancer.
It's also not clear what effect PSA testing might have on prostate cancer
outcomes. Because testing is becoming more common, prostate cancers are
now being found even earlier than they were discovered in the men who took
part in these studies.

Studies of the effect of screening and different treatment options are
under way. Results are expected in the next few years.

Citations:
"Radical Prostatectomy versus Watchful Waiting in Early Prostate Cancer."
Published in the New England Journal of Medicine (Vol. 352, No. 19:
1977-1984). First author: Anna Bill-Axelson, MD, University Hospital,
Uppsala, Sweden.

"20-Year Outcomes Following Conservative Management of Clinically
Localized Prostate Cancer." Published in Journal of the American Medical
Association (Vol. 293, No. 17: 2095-2101). First author: Peter C.
Albertsen, MD, MS, University of Connecticut Health Center.

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