By Danielle Krol, MD (@dailydoseMD)
Younger men who have been diagnosed with prostate cancer may do well to consider surgery over so-called “watchful waiting,” a new study shows.
The new research, published yesterday in the New England Journal of Medicine, is unlikely to end the long-running debate in the medical community over if and when surgery to remove the prostate is needed — particularly since the men in the study were diagnosed before the sensitive prostate-specific antigen (PSA) test was widely implemented to detect prostate cancer in its early stages.
The findings are the latest to come out of a 23-year-long, ongoing study comparing radical prostatectomy versus watchful waiting in 695 men who had been diagnosed with localized prostate cancer.
Between 1989 and 1999, researchers randomly assigned these men to either receive prostatectomy or not. The study found that those younger than 65 who underwent surgery to remove their prostates had a 15.8 percent lower risk of dying from prostate cancer than patients who had not had surgery. They also had a 25.5 percent lower risk of dying from any cause, as well as a 15.8 percent lower risk of the disease having spreading to other organs.
“Our results suggest that surgery may be more beneficial to younger men,” said study author Jennifer Rider, assistant professor of epidemiology at the Harvard University School of Public Health. Rider added that the men under 65 who had their prostates removed were also less likely to need radiation or chemotherapy.
The trial, funded by the Swedish Cancer Society and the U.S. National Institutes of Health, is the first of its kind to entail such an extended follow-up.
Urologists not involved with the research said the findings were important, particularly at a time when many men have concerns about the side effects of going under the knife for prostate cancer.
“This study makes a world of a difference,” said Dr. David B. Samadi, chairman of urology at Lenox Hill Hospital in New York City.
Samadi added that in the years since the study began, the operations to remove the prostate have become more refined.
“Surgery has become much improved,” he said. “ We’ve come a long way.”
“The important finding is that the benefits of surgery have increased over the course of time,” said Dr. Philip Kantoff, director of genitourinary oncology at Dana-Farber Cancer Institute in Boston.
But Dr. Otis Brawley, chief medical officer for the American Cancer Society, said that the results should be interpreted with caution, particularly since the study dealt with men who were not diagnosed using a PSA test – currently the common early detection method used in the U.S.
“That is a very different population from men in the U.S., where PSA screening means most cancers are caught at a much earlier stage,” he said in a statement to ABC News. The concern is that using prostate-removing surgery to treat these very early cancers may not be the best option, as it could mean a drastic surgery to remove a prostate that would never have presented a life-threatening problem.
And Dr. Lee Green, professor of family medicine at the University of Michigan, said more research will be needed before men facing a prostate cancer diagnosis get definite answers to the questions they have.
“It doesn’t prove that radical prostatectomy is better than less radical procedures, and it doesn’t prove that surgery is better than chemotherapy,” Green said. “It just says that surgery is better than doing nothing.”
Prostate cancer is the most common cancer in American men. According to the American Cancer Society, more than 230,000 new cases of prostate cancer will be diagnosed in 2014, and an estimated 29,000 will die from the disease.
Due to more widespread PSA testing, today nine out of 10 men diagnosed with prostate cancer have tumors that are detected at the earliest stage when they’re still confined to the prostate gland. With this in mind, the jury is still out as to whether the results from this latest study necessarily apply to men who are being diagnosed earlier. Some doctors say that more surgery, earlier, could save lives. Others caution that such an approach could lead to overtreatment, offering surgeries – and their side effects – in cases where they are not necessary.
The best advice to help men diagnosed with prostate cancer cut through the confusion is for them talk to their doctor. This is exactly what the American Cancer Association recommends — both when it comes to screening and early detection as well as treatment. Every patient should talk to his doctor about the risks and potential benefits of prostate cancer screening before making a decision. And even after a decision about screening has been made, the discussion of pros and cons should be repeated as new information is made available.