In the past, "watchful waiting" -- closely monitoring for signs and symptoms -- has often been the recommendation for many prostate cancer patients.
Now, it seems elderly men who have the beginnings of prostate cancer may do better if they receive treatment, rather than just waiting to see how their cancers progress, according to new research in the Journal of the American Medical Association.
The study, which was conducted over a 12-year period, looked at prostate cancer in 44,630 men aged 65 to 80 years.
Of the men who received radiation treatment or had their prostates removed, only 24 percent died. By comparison, in the watchful waiting group 37 percent of the men died.
These results were seen across all categories of patients, including older men, African-American men, and men with low-risk disease.
But experts continue to debate which men should be treated aggressively for prostate cancer and which men are probably better off not being treated because their cancer is slow-growing.
In general, the most benefit is seen in younger men, but this study suggests that even men aged 75-80 enjoy longer survival with treatment.
Intervention Could Help Many
Many experts say the findings could be beneficial for a number of patients.
"It is the first convincing study that treatment of screen-detected cancers is beneficial," said Dr. Eric Klein from the Cleveland Clinic. "This will put a big dent in the argument of those who advocate watchful waiting."
"Showing that treatment of men over 65 who have clinically localized prostate cancer saves lives has broad and important implications," said Dr. William J. Catalona, professor of urology and director of the Clinical Prostate Cancer Program at Northwestern University Feinberg School of Medicine in Chicago. "It suggests that watchful waiting strategies that have gained much recent attention carry a significant risk of unnecessary death from prostate cancer."
"If the results are valid, this data provides compelling evidence that local treatment is important in prostate cancer," said Dr. Howard Sandler, professor and senior associate chair of the Department of Radiation Oncology at the University of Michigan. "This study provides additional encouragement that active treatment will decrease the chance that my patients will die from prostate cancer."
Some physicians said the findings may even change the way they treat their patients.
"I will probably be more inclined to recommend treatment instead of waiting," said Dr. L. Michael Glodé, professor and Robert Rifkin Chair at the University of Colorado Cancer Center.
"Prior to this study, the only study showing a benefit for treatment was in men under the age of 65; those were the men I most strongly urged immediate treatment," said Dr. Robert E. Reiter, professor of urology and director of research at University of California at Los Angeles. "The benefit of this article is that it does suggest that treating healthy elderly men with significant tumors may be beneficial, which is nice to hear."
Some Experts Say Results Not Clear-Cut
"As much as I like the message, I remain skeptical," said Dr. Patrick Walsh from the Brady Urological Institute at The Johns Hopkins Hospital in Baltimore. He says other factors could be at play and suggests that the group receiving treatment may have been comprised mostly of healthier men.
"It is an interesting study, and the large numbers give credibility, but it is an observational study with its inherent limitations," said Dr. Jerome Paul Richie, chief of urology at the Brigham and Women's Hospital in Boston.
"I don't think this study will significantly change my practice," he said.
Other experts took a stronger position.
"Studies such as this are an excellent reminder that you can't shortcut research," said Dr. Paul Godley, associate professor of medicine in the Division of Hematology and Oncology at the University of North Carolina at Chapel Hill.
He says randomized clinical studies -- those in which patients are randomly assigned to receive different types of care -- are needed to arrive at an unbiased result. Instead, in this study, the course of treatment (or lack thereof) was already decided for the patients, and they were simply observed.
"It may be that the observation group in this study was not treated because their physicians thought that their disease was unlikely to benefit from surgery or radiation as their tests indicated that they were at high-risk to have recurrent disease after therapy," Godley said.
"The results from observational studies are hopelessly biased," he said. "The sophisticated analyses by the authors do not alter this reality."
More Research Necessary
"Unfortunately, we are faced with the same old problem," said Dr. Peter C. Albertsen from the Division of Urology at the University of Connecticut Health Center in Farmington, Conn. "In the absence of a randomized trial you never know why which patients selected each strategy."
"There must be more randomized controlled trials with long-term follow up," said Dr. Larry Lipshultz, professor and chief of the Division of Male Reproductive Medicine and Surgery at Scott Department of Urology at the Baylor College of Medicine.
These studies are thought to be the best way to get to the bottom of such important issues, and experts agree that more participation in such trials by patients will increase our knowledge of prostate cancer and many other diseases.
For the time being, some experts recommend that screening itself should continue to remain the first step.
"I suggest that all men who see me in the office regardless of age have a prostate test," said Dr. Mark Soloway, professor and chairman of the Department of Urology at the Miller School of Medicine at the University of Miami. "This is like having their cholesterol checked."
If the test for prostate cancer markers indicates a problem, doctors can then decide whether treatment is needed.
But this decision must be made with the individual patient in mind, experts agree.
"What might be true for one 75-year-old is not necessarily true for another," said Dr. Anthony Smith, professor and chief of the Division of Urology at the University of New Mexico School of Medicine.
"This is where the art of medicine comes in."
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