Prostate Surgery May Be a Better Option
Cuts Cancer Death More Than Watchful Waiting, but Not Everyone's a Candidate
Sept. 11, 2002 -- For the first time, a study shows that prostate surgery cuts the risk of prostate cancer death. But it still doesn't tell most men what to do when they hear the words, "You have prostate cancer."
"I think that we now have much better underpinnings for patients and doctors to have rational discussions -- and make rational decisions -- about what to do with early prostate cancer," study leader Lars Holmberg, MD, PhD, tells WebMD. "We have done away with some of the doubts on surgery. But should every patient with early prostate cancer be operated on? The answer is no. For every stage of a man's life, one must weigh the risks and benefits."
Holmberg, director of the Regional Oncologic Center at University Hospital in Uppsala, Sweden, and colleagues report their findings in the Sept 12 issue of TheNew England Journal of Medicine.
"This study will have the most impact on people opposed to early screening and diagnosis of prostate cancer," editorialist Patrick C. Walsh, MD tells WebMD. "It has been the mantra of these people that there is no reason to treat early prostate cancer, as there is no evidence that early treatment saves lives. Now they can't say that. As this study matures, the data will show that surgery saves lives." Walsh is urologist-in-chief at Johns Hopkins Hospital and director of the department of urology at Johns Hopkins University. He invented the nerve-sparing technique that makes it far less likely for men to suffer impotence after prostate surgery.
Holmberg's team looked at 695 men who'd just been told they had early-stage prostate cancer. Half of them were assigned to get immediate surgery to remove the prostate. The other half did not get surgery but instead got careful medical follow-up -- so-called watchful waiting.
Eight years later, the men who got surgery had about 7% fewer deaths from prostate cancer. Overall deaths in the two groups were about the same. The most telling statistic, however, is that men who had surgery had 14% fewer cancers spread to different parts of the body. This spread is generally fatal in two to three years. And as prostate cancer often takes 20 or more years to kill a man, it seems likely that surgery is a better choice than watchful waiting.
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."