Surgery, Waiting a Toss-Up for Prostate Cancer Patients

Study finds advantages and disadvantages to both approaches

WEDNESDAY, Sept. 11, 2002 (HealthDayNews) -- You're diagnosed with prostate cancer, and your choices are to have the organ surgically removed or to have your doctor keep a close eye on the slow-growing tumor.

What do you do? A Swedish study finds that both options have their advantages and disadvantages when it comes to the quality and length of a man's life.

The study, appearing in tomorrow's issue of the New England Journal of Medicine, doesn't cover all the options, but it does provide data from a long-term, controlled study on the major choice that must be made, between watchful waiting or surgery to remove the cancer. And the study results indicate that there is no simple, yes-or-no answer that applies to all men.

For example, the study, which enrolled 695 men with newly diagnosed prostate cancer, found that surgery reduced the death rate from prostate cancer. The survival curves began to diverge about five years after diagnosis, with 8.9 percent of the men assigned to watchful waiting dying of their cancers after an average of 6.2 years, compared to 4.6 percent of those who had surgery.

But the overall death rate was the same for both groups, with more men who had surgery dying of other diseases -- in many cases, other cancers -- than those in the watchful waiting group.

And the incidence of severe side effects was greater for those men who had surgery, with 80 percent of them experiencing impotence, compared to 45 percent of those in the watchful waiting group, and a 49 percent incidence of urinary incontinence after surgery, compared to 21 percent for watchful waiting.

The study wins high praise from American experts. "Very impressive," says Dr. Patrick C. Walsh, director of the Brady Neurological Institute at Johns Hopkins Hospital and author of the book Dr. Patrick Walsh's Guide to Surviving Prostate Cancer, who wrote an accompanying editorial. "Very exciting," says Dr. Durado Brooks, director of prostate cancer for the American Cancer Society.

The study helps to resolve one major controversy, about the value of treatment vs. watchful waiting, Walsh says: "Until now, there has been no evidence that treating prostate cancer saves lives," Walsh says. "I don't know of any other randomized study which has been able to show a difference in survival after a relatively short interval. This study says that diagnosing prostate cancer at an early stage and treating it will cure prostate cancer."

Brooks pays more attention to the overall death rate. The excess deaths of other causes in the watchful waiting group is "puzzling, with no clear explanation," he says. So, he adds, "this study does not say that if you have surgery for prostate cancer, your life will be prolonged. It says that the chance of dying from prostate cancer is reduced."

And a man faced with the decision "must be aware of the greater likelihood of experiencing sexual dysfunction and urinary incontinence when he enters the decision-making process," Brooks says.

Walsh agrees, and he says the outcome of that process can be affected by the patient's age, outlook on life, and individual preferences.

An older man, someone in his late 70s, might well choose to avoid treatment, Walsh says. "About a third of patients are candidates for watchful waiting," he says. "Someone whose life span is not expected to be 10 years might choose watchful waiting."

For those who choose treatment, the Swedish study does not touch on another choice, radiation therapy vs. surgery, Walsh says. "If you are young and healthy and can have the operation done by skilled surgeons, there is no better way to cure prostate cancer," he says. "If you are 70 or older, the side effects of surgery are much greater and radiation therapy is the way to go."

Right now, there is no definitive information comparing the outcome of radiation therapy and surgery, Brooks says. Two ongoing studies are expected to provide that information, but their results will not be available for four or five years.

There is yet another complication. All the Swedish cases were diagnosed by clinical evidence of cancer. Most prostate cancer cases today are diagnosed by elevated levels of prostate-specific antigen, which give an earlier warning sign. Walsh believes that the surgery-vs.-watchful waiting numbers in such cases will be the same as in the Swedish study, but there is no definitive proof of that.

In the end, Brooks and Walsh agree that a decision is up to each individual patient. "Doctors should tell patients what they know about the advantages and limitations of each choice, giving the patients all the information they can to allow them to make their own decision, based on what they value most in life," Brooks says.

"What I advise is for men to think backward," Walsh says. "If you are 65 and healthy, a good candidate for either option, think about what will happen if things don't go well. If you consider surgery, think about never having an erection and wearing a pad for urinary incontinence. If you consider radiation therapy, think about what you would do if your prostate-specific antigen reading starts going up after five years."

What To Do

Read a primer on prostate cancer and its treatment from the National Cancer Institute or the support group Us Too!

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