Prostate Surgery May Be a Better Option
Cuts Cancer Death More Than Watchful Waiting, but Not Everyone's a Candidate
Or is it? The study began in 1989 -- before PSA blood tests became routine. PSA tests offer much earlier detection of small prostate cancers. As many as one in five men with very small prostate tumors may do better with watchful waiting, Walsh's editorial suggests.
Holmberg notes that there are men for whom watchful waiting is the better option.
"Let's say you are an older man and you have a very small and less aggressive prostate cancer, and you feel that the side effects of incontinence and impotence would bother you very much in your life," Holmberg says. "In that kind of situation you would opt for watchful waiting."
Or say you had other medical conditions that would make surgery a high-risk proposition. Again, you might want to choose waiting. On the other hand, if it seems to you that the side effects of surgery are acceptable, and you have the kind of prostate cancer where your risk is maybe not very high but substantial -- and you wouldn't like to risk that -- perhaps surgery is the better choice."
A second part of the Swedish study compared quality of life for men who underwent prostate surgery and those assigned to watchful waiting. After about four years, the two groups reported about the same quality of life. However, surgery -- performed in most cases without use of Walsh's nerve-sparing technique -- resulted in more impotence and urinary leakage. Watchful waiting, however, also resulted in significant impotence -- and in greater inability to empty the bladder.
"The point this makes is the one I have been trying to make to waken the skeptics: Waiting can cause side effects," Walsh says. "Men who have prostate cancer and do nothing don't just wait five years and wake up dead. You go through five years of life-changing events."
Still, not all side effects are equal. Which are worse? That depends on the individual.
"Different people have different degrees of bother from side effects," Holmberg says. "Incontinence is not the same kind of problem for every person. It will be kind of guesswork to counsel people on which treatment they should choose, because when we see how much people are bothered, well, that is after the fact. To decide what kind of treatment -- whether watchful waiting or [prostate surgery or radiation] -- it is still a very difficult decision. At least now we have these data to give you. It makes the guesswork more informed."