The largest and longest trial to compare treatment options for prostate cancer has found little difference in outcomes between men who underwent surgery vs. those who were simply observed by their doctors.
Led by a researcher at the Minneapolis VA Medical Center, the 20-year national study provides the best evidence yet that most men can live with their prostate cancers, avoiding the potential risks of surgery. The results, though, did show that surgery was probably a better option for younger men with long life expectancies, and some urologists dispute the findings.
“Our results demonstrate that for the large majority of men with localized prostate cancer, selecting observation for their treatment choice can help them live a similar length of life, avoid death from prostate cancer, and prevent harms from surgical treatment,” said Dr. Timothy Wilt, an internist at the Minneapolis VA who led the study, in an e-mail.
A decade ago, doctors often recommended surgery or radiation to remove prostate cancers, Wilt said, but the results suggest a more conservative course in most cases.
Dr. Christopher Knoedler of Metro Urology in the Twin Cities said about one-third of patients in his practice with prostate cancer undergo observation rather than surgery. He remains a strong advocate for regular prostate screenings and offers prostate removal surgery to most patients, but said he will use the study’s findings in discussions with patients who might not need surgery.
“Some patients get that C word and they want to be treated,” Knoedler said, “but they don’t always need to be treated.”
More than 700 men with prostate cancer were randomly assigned between 1994 and 2002 to two treatment groups, and researchers then monitored their progress.
Because prostate cancer is commonly found in older men, most study participants died during the long course of the study. But prostate cancer was the cause of death in 27 men who underwent surgery and only 42 whose cancers were monitored by their doctors — a statistically negligible difference, the study concluded.
Avoiding surgery means avoiding some of the potential complications, including incontinence and sexual dysfunction. These problems were more common in the men who underwent surgery, according to the results, which were published Thursday in the New England Journal of Medicine.
Surgery was associated with a lower death rate in men whose prostate cancers presented intermediate risks, but not for the cancers that presented the lowest or, surprisingly, the highest risks. Wilt said surgery may still be the best option for men with long life expectancies whose cancers are detected when they are younger.
New surgery techniques
The findings are likely to draw objections from some urologists, who bristled in 2012 when the U.S. Preventive Services Task Force recommended against routine use of prostate-specific antigen (PSA) blood screenings for prostate cancer in men. (The task force has since recommended that men between 55 and 69 consult their doctors about PSA screening.)
Knoedler said that, because of improved surgical techniques, complications that might have been more common at the time the men in the study underwent their surgeries are less likely today. Knoedler operates at St. Johns Hospital in Maplewood and United Hospital in St. Paul, using a robotic surgical system that he said reduces errors.
“There’s a real art to parsing out who needs to be treated and who doesn’t,” he said.
Prostate cancer remains the second-leading cause of cancer death in men, even though there have been dramatic declines over the past three decades in deaths and cancers that aren’t diagnosed until advanced stages.
Many doctors observe patients with routine tests, and then perform surgery or radiation later if PSA or biopsy results suggest a worsening of the disease. The approach used in the study was more conservative, avoiding follow-up biopsies for the most part and performing delayed prostate removal surgery only if patients’ actual physical health worsened due to their cancers.
The decision whether to operate is fairly clear in some cases — such as a young healthy man whose father died of prostate cancer vs. an old man with other conditions who isn’t expected to live another 10 years.
Get a second opinion
Decisions for many men aren’t so clear-cut, though, said Dave Hulbert, a wellness coach who volunteers with the Minnesota Prostate Cancer Coalition. Even with the new guidance, he encouraged men to seek second opinions as many doctors are predisposed to certain approaches.
Hulbert underwent prostate removal surgery and radiation in 2009 along with a host of other treatments due to a recurrence of his cancer. He now wonders whether all the treatments were necessary.
“I always advocate more opinions,” he said.
On the other hand, Wayne Sticha, a Lindstrom prostate cancer survivor who is organizing a motorcycle ride to raise cancer awareness, said he worries this information will be used by insurance companies to convince patients not to pursue costly treatments.
“Had I done what this study told me do, which was to just wait and watch for it, [the cancer] would have moved on to a lymph node” and gotten worse, said Sticha, who had his prostate removed in 2009.
In addition to examining deaths and surgical complications, the study also examined patients’ health and attitudes. Over 10 years, men who underwent observation were no more worried about their prostate health than men who underwent surgery — indicating that they were comfortable with their decisions to leave their cancers alone.