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Watchful Waiting or Surgery for Prostate Cancer?



What should be done in men who have prostate cancer? On first examination, it might seem that the obvious answer would be “take it out of course!” But it actually is not so simple. In fact, the management of early stage prostate cancer (a cancer that has not spread beyond the prostate) has been one of the most difficult and controversial questions in medicine.

On the one hand, prostate cancer is one of the leading causes of cancer death in men. On the other hand, only a fraction of men with early stage prostate cancer are actually harmed by the cancer. In most cases, the cancer will grow so slowly that it will never cause meaningful symptoms. Most men with prostate cancer, especially older men, outlive their prostate cancer and will die of something other than prostate cancer.

Further, the vast majority of men who are treated for prostate cancer (whether by surgery or radiation) will be harmed in some way by treatment. The harms are often substantial. Treatment more often than not leads to erectile dysfunction, and some degree of incontinence is also common. Prostate cancer surgery is a major operation and a small number of men will die as a complication of surgery. Others may have surgical complications that shorten life. Also, many older men recover poorly from major surgery and are left with disabilities in activities of daily living following surgery.

If one had a crystal ball, one might choose to operate in men who were destined to develop lethal complications from their prostate cancer and not operate on men who were destined to never have complications from their prostate cancer, saving them from the harms of treatment. Of course, we have no crystal ball. So, there has not been a consensus about exactly who should have surgery (or radiation) for prostate cancer. Many have believed that the evidence supporting surgical therapy is weak and that “watchful waiting” without surgery or radiation is preferable in most patients to surgery.

A recent study in the New England Journal of Medicine provides important new information about which patients benefit from surgery. It strongly suggests younger patients who have surgery live longer, while older men derive no survival benefit from surgery.

The investigators enrolled 695 with localized prostate cancer between 1989 and 1999 to either surgery (radical prostatectomy) or watchful waiting. The men were followed for up to 15 years. There were striking differences in the impact of surgery in younger and older men.

  • Among those younger than 65 years old, 34% of those who had surgery died while 47% of those who did not have surgery died. This means that for every 7 younger patients who had surgery, 1 more patient survived 15 years.
  • Among men over the age of 65, there was absolutely no survival benefit from surgery. 57% died after 15 years in both groups. This mean that older men suffered all the complications of surgery with no survival benefit in return.

A caveat should be kept in mind. This study was done before PSA screening was common. Most of the cancers were discovered because of symptoms, or because a prostate nodule was detected on physical exam. Cancers that are detected by PSA are less advanced, and the period of time needed for them to cause complications that become lethal is considerably longer. Thus, the age at which surgery becomes nonbeneficial for PSA detected tumors would be younger. It is hard to know for sure what this age cutoff would be, but I would guess around 60.

Another caveat is that the likelihood that an early stage prostate cancer will progress and cause complications is directly related to the years of remaining life expectancy. Age is only one factor that determines this. Thus, a man who is very healthy (in terms of health, younger than their age), may benefit even if they are somewhat older than these age cutoffs. On the other hand, a man who has worse health may not benefit even if younger than these age cutoffs.

This study is very helpful in guiding decision making for early stage prostate cancer. While decisions will still depend greatly on the preferences and values of each patient with prostate cancer, we now have good reason to believe that that younger men derive some benefit from definitive surgical treatment and that older men are probably better served by watchful waiting.

The men who agreed to be randomized to help us learn how to best manage prostate cancer are owed our gratitude and thanks.

by: Ken Covinsky

Comments

that is a why a patient needs to ask for the doctor's advice. They are experts but of course, we also need to be aware that for every decision we will decide there are consequences. there is no doubt for any medical procedures we are going through there will be side effects.
Matt Cooperberg said…
This is indeed a useful summary of the NEJM. However, neither the article nor the blog entry addresses the heterogeneity of prostate cancer adequately. Most prostate cancers diagnosed in the U.S. are low-risk, grow very slowly, and pose minimal threat to life. Such tumors often don't need to be treated immediately no matter the age at which they are diagnosed. However, the minority of prostate cancers which are aggressive and considered high-risk are frequently lethal even when identified among men in their 70s and 80s (see JAMA 2009; 302:1202). In the U.S. we have problems of both over-treating low-risk disease and under-treating high-risk disease, and these problems are worse among older men (see Journal of Clinical Oncology 2011; 29:228, http://tinyurl.com/jco-agerisk). Treatment decisions need to be guided by prostate cancer disease risk and patient life expectancy, not by chronological age.

Matthew Cooperberg, MD, MPH
Dept of Urology
University of California, San Francisco
Alex Smith said…
We need a new name for watchful waiting. It has alliteration but sounds too much like do nothing still. I propose the "avoid risks of impotence and incontinence strategy." This captures the preference of people who choose this approach.
Are you okay? said…
Cancer in the Gland:

I am curious that you did not mention biopsies in your blog.

I am in the older age group - 69.
I am an otherwise very healthy well exercised person who has no apparent symptoms.
An elevated PSA led to a digital examination (found a bump) led to a biopsy. The biopsy returned 10 cancerous samples out of 10. With regard to aggressiveness of the cancer - 5 being the most aggressive, all of the biopsy samples scored 4's and 3's, but predominantly 4's. On the Gleason scale the score was 7 out of 10; indicating the cancer may or may not have spread outside the capsule called prostate.

The consulting surgeon and my GP both recommended removal. Also my GP indicated surgery is required to see if the cancer has escaped.

I am scheduled for surgery in about 10 days and intend to go ahead with it.
Would you?
JBurke said…
In 2004, I found out I had prostate cancer due to a large percentage increase in my PSA (2.7 to 4.7) score. After visiting the largest Urologist group in Los Angeles, my Gleason score was a 3/3 on both sides of the prostate. A whole body bone scan revealed the cancer was local. Being 58 years old, I was told to go ahead with surgery, Radical Prostatectomy. It was done, with no major problems, some impotence. Now it is 2011, and the cancer has returned!! An increase in the PSA alerted me, and more scans revealed a tumor in the prostate bed. Surgery again is out of the question, and I would like to know should a person go through the medical procedure again, radiation the procedure suggested. At 65 should I ignore this new tumor or proceed. The major question is what is the best treatment for prostate cancer?
To Are You OK? and JBurke, both wondering what to do about prostate cancer - Do nothing in a hurry, you will regret it, as studies show. Do some research -particularly European studies - before agreeing to any treatment unless you have symptoms that interfere with your functioning. Treatment doesn't do much in terms of survival.

Have you looked into Dr. Liebowitz' Compassionate Oncology website and hormone treatment? He pioneered giving men with prostate cancer hormone treatment and has impressive data to support survival increases, even in men with very advanced prostate cancer. Too many men have the cancer return after prostatectomy and radiation.
I have been studying prostate cancer for years as a researcher/academic, and have a blog that discusses problems with the research we are given to support treatment. It is http://caroleschroederblog.blogspot.com/
and in it I critique the new NEJM study -

My husband had numbers similar to Are You OK's, and used Dr. Liebowitz's treatment several years ago with no return yet. If it should return, he will do hormone treatment again - it is reversible for one thing, and seems the best option to keep the cancer from causing problems. Carole Schroeder, PhD RN
Finding the right doctor is probably the most important thing. Although these procedures have become more common, they are no less serious than a regular surgery, and a choice of doctor is just as important.

aljur
Great post, what you said is really helpful to me. I agree with you anymore. I have been talking with my friend about, he though it is really interesting as well. Keep up with your good work, I would come back to you.
James Makker, MD

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