March 6, 2014
News Review From Harvard Medical School -- Study: Prostate Surgery Boosts Survival
Men with prostate cancer may live longer if they have surgery rather than "watchful waiting," a long-term study suggests. The benefit was strongest for younger men and those with medium-risk tumors. At the time the study began, the PSA test was not widely used. Most men were diagnosed because they had symptoms or a lump in the prostate. The study included nearly 700 Swedish men with prostate cancer. They were randomly assigned to receive prostatectomy (removal of the prostate) or no immediate treatment. In the next 23 years, 56% of the men in the surgery group and 69% in the watchful-waiting group died. Prostate cancer was the cause of death for 18% of the surgery group and 29% of the other group. Men in the surgery group also were less likely to have their cancer spread or to need anti-hormone treatments. The most benefit occurred among men who were under age 65 when diagnosed. Men who had intermediate-risk cancers also gained a greater survival benefit from surgery than men with low- or high-risk cancers. The New England Journal of Medicine published the study. HealthDay News wrote about it March 5.
By Robert H. Shmerling, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
Prostate cancer is one of the most common -- and confusing -- types of cancer. About 1 man out of 7 develops prostate cancer during his lifetime. Nearly 30,000 men in the United States die of the disease each year.
But here's the confusing part:
- Many men with prostate cancer would be better off not knowing they have it. That's because, for many men, prostate cancer grows so slowly that it never poses a health risk.
- Treatment of prostate cancer may cause more trouble than the cancer itself. For example, surgery and radiation may lead to problems with urine control or sexual function.
- The screening test for prostate cancer -- the PSA blood test -- is often abnormal even when the man does not have cancer. These "false positives" are a common source of anxiety. They often lead to more invasive and unhelpful testing. Because the PSA is such an imperfect test, many experts now recommend against routine screening with PSA.
A key question surrounding the diagnosis of prostate cancer is which tumors need treatment. While some are best left alone, others need treatment.
Sorting out who benefits most from surgical removal of the prostate is the subject of a new study. Researchers divided nearly 700 men with cancer that had not grown outside the prostate into 2 groups. One received radical prostatectomy. This includes removal of the entire prostate gland and some surrounding tissue. The other group had no immediate treatment.
During the next 23 years, those who had surgery:
- Had a lower overall risk of death (56%) than those in the untreated group (69%)
- Had less spread of cancer (26% vs. 38%)
- Had a lower risk of death from prostate cancer (18% vs. 29%)
The benefits of surgery were most impressive for two groups:
- Men younger than age 65 at the time of diagnosis
- Men whose tumors were considered "intermediate-risk" (not the highest or lowest risk, based on PSA level and the appearance of the tumor cells)
But there were downsides to surgery. One man died. The surgically treated men had more "distress" related to side effects, including urinary problems.
These findings should help improve the quality of doctors' advice for men diagnosed with prostate cancer. However, it's important to find out each man's preferences. Issues to discuss include:
- The risks of treatment (such as urinary problems)
- The risks of non-treatment (including spread of the tumor and need for later treatment)
- Competing priorities (such as other, more pressing medical problems)
What Changes Can I Make Now?
Learn more about prostate cancer. Factors that affect risk of the disease include:
- Age -- Most cases of prostate cancer are diagnosed in men older than age 65.
- Family history -- Having a father or brother with prostate cancer increases your risk of developing the disease.
- Ethnicity -- African-American men are at an increased risk of developing prostate cancer compared with white men.
You also can take steps that may prevent prostate cancer or help to detect it at an early stage. Here are some options to consider:
- Change your diet. Prostate cancer tends to be less common among men who eat a low-fat diet that's high in fruits and vegetables. Eating tomatoes and other sources of lycopene has been touted as a way to lower prostate cancer risk. However, the actual value of this is uncertain.
- Have a prostate examination. A rectal exam can determine whether your prostate is enlarged or has growths suspicious for cancer. The overall value of routine prostate exams is also uncertain.
- Have a PSA test. As mentioned, the overall usefulness of PSA screening may be low. Ask your doctor whether he or she routinely recommends PSA screening and why it is (or isn't) a good idea for you.
- Have a biopsy. If you have a growth or irregular area noted during your prostate exam, your doctor may recommend a biopsy. The results can help you and your doctor make an informed decision about whether to have treatment or to consider "watchful waiting."
- Take finasteride (Proscar) or a related medicine. These medicines can shrink the prostate and improve urination. However, studies suggest they may also lower the risk of prostate cancer for those at high risk. The overall benefit of this approach is controversial, however. Some studies have found that taking these medicines may increase the risk that if you develop prostate cancer it will be a more aggressive type.
What Can I Expect Looking to the Future?
This new study provides much-needed information regarding the usefulness of surgery for prostate cancer. Despite the benefits of surgery reported, there are significant risks linked with surgery. And a sizable proportion of the "watchful waiting" group did well without any treatment over decades. We badly need better tests, not only to identify men with prostate cancer, but also to determine which men will do well without treatment.