Prostate Cancer: Surgery Rarely Best, Researcher Suggests

Men should skip PSA testing and surgery, a researcher says; some doctors differ.

ByDR. SEAN TACKETT, ABC News Medical Unit
July 18, 2012, 3:28 PM

July 18, 2012— -- Robert Ginyard is a 49-year-old small business owner from Baltimore. He started having prostate-specific antigen (PSA) testing earlier than most -- age 40 -- because his father had been diagnosed with prostate cancer when he was in his 40s. When, at age 47, his PSA went from 4.8 to 7.1 he was referred to see an urologist. His biopsy showed cancer.

And then there's Eddie Carrillo, 67, a contractor from Los Angeles. He saw his doctor when he was 53 for abdominal discomfort and had a PSA of 7. His biopsy also showed cancer.

Ginyard said he discussed his options at length with his wife and two daughters. Ultimately he opted for surgery. After six months of difficulty with urinary continence and sexual performance, he found himself cancer-free and with no difficulties. He says he is "100 percent satisfied" with his decision to remove his prostate.

Carrillo said he felt pretty healthy, had a number of family members who had side effects from treatment for prostate cancer, and "just didn't like invasive operations." He selected a "watch and wait" approach. For the last 14 years, he has undergone periodic PSA testing and prostate biopsies. He is still feeling healthy, living with prostate cancer. His approach to prostate cancer is "not to be afraid of it. Deal with it, because you can't run from it and it can be lived with."

Two men who opted for very different approaches to basically the same disease.

Now, a new study is stirring the coals as to whether doctors should urge more men to opt for Carrillo's approach and avoid prostate cancer surgery. At stake, potentially, is the health of millions of American men. And not all doctors agree that surgery -- and PSA testing along with it -- should be taken off the table.

The goal of a new study in the New England Journal of Medicine was to see whether observation would be better than surgery for early prostate cancer.

It included 731 men diagnosed with prostate cancer after having high PSA levels. Half of the men were assigned to have surgery, while the other half were assigned to be observed -- with PSA testing every six months and bone scans to look for tumor spread -- every five years.

After 12 years, 47.0 percent of men assigned to surgery died, compared to 49.9 percent of men assigned to observation -- a difference that was not statistically significant. Meanwhile, more than one in five of the men who underwent surgery had adverse effects from their operation -- though men with very high PSA scores (greater than 10) did have a significant benefit from surgery.

Based on their findings, Dr.Timothy Wilt, lead author on the study, concluded that "observation is a wise and right decision for men with prostate cancer detected by PSA." He said that his study agreed with the recent recommendation by the United States Preventive Services Task Force (USPSTF), which in May 2012 said that PSA should not be tested in men for prostate cancer screening.

Nearly all of the experts contacted by ABC News acknowledged that this study helps identify which patients do not require surgery for their prostate cancer.

However, most of these experts disagreed with the notion that all prostate cancer detected with PSA should simply be observed.

"With early diagnosis and improvements in treatment during the past 20 years, the prostate cancer death rate has decreased by 44 percent in the U.S.," said Northwestern University's Dr. William Catalona, medical director of the Urological Research Foundation and the doctor who developed the PSA test for cancer screening. "This trial should not provide men with another excuse not to get tested or treated for prostate cancer."

"Rather than characterizing the study as showing no benefit from surgery compared to observation, this study provides evidence that surgery will reduce metastasis and death from prostate cancer particularly in men with intermediate or high risk tumors," said Bruce Trock, professor and director of the Division of Epidemiology in the Brady Urological Institute.

Doctors Differ on Course of Action for Prostate Cancer

Many even felt that the study actually supports testing for PSA.

"This study does not undermine the value of PSA but underscores the importance of proper use of PSA in appropriate populations," said Dr. Phillip Kantoff, professor of medicine at Harvard's Dana Farber Cancer Institute. "The USPSTF fails to distinguish the value of PSA in saving lives from the problem of overtreatment."

While the experts could not agree on how to interpret the findings of this study, they all felt that more research was needed to find better tools to identify which prostate cancers would be slow-growing and harmless -- and which ones could be lethal. Technological advances such as prostate MRI and targeted biopsy are promising options undergoing study.

In the meantime, Ginyard and Carrillo had similar advice for patients who get the news they have prostate cancer.

"Really take time to do your research," Ginyard said. "Make the decision by gathering as much information as you can."

"Make sure you get a second opinion," said Carrillo.

Dcotors agreed that this is sound advice.

"Prostate cancer is not a one-size-fits-all disease. It's really a spectrum," said Dr. Martin Sanda, a urologist at Harvard's Beth Israel Deaconess Medical Center.

"The message to patients should be, get tested, have a biopsy if necessary, but be very careful before agreeing to treatment," said Dr. Peter Scardino, chief of surgery at Memorial Sloan-Kettering Cancer Center in New York. "Make sure you have a cancer that really poses a serious risk to your life and health and that the treatment is not worse than the disease."

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