Is It Worth The Wait? New Prostate Cancer Study Backs Aggressive Surgery Rather Than ‘Watchful Waiting’

Surgery to fully remove the prostate, once thought to be unnecessarily risky during the early stages of prostate cancer, is now receiving a second look within the medical community.

 

The findings of a decade-long prostate cancer study published in the New England Journal of Medicine in May revealed that a radical prostatectomy during early-stage prostate cancer reduces long-term complications of the disease and also allows for the prolongation of life. The long-term implications of the surgery were compared against those of a more common course of treatment and observation of the disease, dubbed ‘watchful waiting.’

The study, performed by a Scandinavian group of researchers, randomly assigned 695 men with early prostate cancer to one of two groups between 1989 and 1999. One group received the prostatectomy procedure, and the other was placed on a course of watchful waiting. Another treatment method, radiation, was not a part of the study.

Watchful waiting was the standard of prostate cancer care for many years because the disease advances slowly, and some prostate cancers never progress. It is still a valid option for many men. In fact, the Scandinavian study published in the NEJM follows on the heels of a study that appeared in the Journal of the American Medical Association that studied and subsequently backed the practice of watchful waiting.

Dr. George Bowers, medical oncologist at Cooley Dickinson Hospital, explained that both monitoring the disease and attacking it with aggressive surgery have their place in the treatment of prostate cancer.

“You have to pick your patient,” Bowers said, referring to the several factors that could contribute to the best course of action, including a man’s age, how early the cancer was discovered, and how aggressive it appears to be.

But especially in the case of younger men, many physicians agree that surgery may prove to be the optimal choice.

“The study illustrates that there may be something we can be doing that is, in fact, better than nothing,” said Dr. Wilson Mertens, medical director of cancer services for the Baystate Cancer Program.

After years of observation of both groups, the study’s observation phase concluded in 2003, and last month released the results that 8.6{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the men assigned to surgery and 14.4{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the men assigned to the watchful waiting tract died of the disease before the close of the study. The study group published its conclusion that radical prostatectomy reduces disease-specific mortality. It also concluded, however, that surgery also reduced overall mortality rates and the risk of progression of the disease, calling the reduction of local tumor progression “substantial.”

“The study is something of a breakthrough,” said Mertens. “Generally, I’d say surgery is already becoming the norm. But there is still some controversies, and after 10 years of observation, the results of this study have matured into a sort of gold standard; it proves that we can save lives and allow men to live longer with this surgery.”

The study also calls attention to a major health issue for men. Prostate cancer is the most common cancer among men, striking about 230,000 men in the U.S. alone, according to the American Cancer Society. Of that number, 30,000 will die. But the controversy Mertens referred to are one reason why surgery is not always considered as the first line of defense.

Mertens explained that in some cases, men can experience incontinence, loss of ejaculatory function, chronic pain, or loss of erectile function following the surgery, which removes the entire prostate gland. Those side effects are the major downsides of the surgery, he said, but removing the prostate is much more effective in controlling the disease.

“If it is not controlled, the next organ that is generally affected are the bones,” he said. “And if it spreads, we can manage the disease, but we can’t stop it.”

Bowers agreed that the study backs the medical opinion that surgery may be the more ideal option for younger men, who may be able to curb the disease and enjoy a longer, more quality life. It could also prolong life for older men, or men with advanced tumors.

“The surgery decreases the spread of the disease and increases the overall quality of life,” Bowers said, adding that although many cases of prostate cancer progress slowly, some are also very aggressive and very deadly, calling added importance to the weight of the study.

“I think for a long time we have taken a very nihilistic view of prostate cancer,” he said. “If the cancer is aggressive, we say those men are more likely to die, and if it is slow in progressing, we say those men have a better chance regardless of the treatment. That suggests that treatment doesn’t matter, but this study suggests tells us that just isn’t true.”