May 3, 2005 -- Many men with early-stage prostate cancer who are treated with either surgery or radiation might fare just as well with no treatment at all.
The issue of how aggressively to treat men with prostate cancer arises frequently. That's because prostate cancer often progresses very slowly.
And now researchers have found that men with cancers confined to the prostate that do not appear aggressive -- called low grade -- have a low risk of the cancer worsening over a 20-year period.
The findings appear to contradict another large 20-year study from Sweden, published last June. Swedish researchers reported that prostate cancer deaths increased dramatically among untreated men between 15 and 20 years after a diagnosis of early-stage prostate cancer.
That study was widely seen as validating an aggressive treatment approach for early-stage prostate cancers. But Peter C. Albertsen, MD, who led the new study, says he was skeptical of those findings.
"We went back and analyzed our data, and did not find an accelerated death rate among [untreated] men who were still alive 15 to 20 years after their diagnosis," the University of Connecticut Health Center urology professor tells WebMD. "In fact, if anything, we found that the death rate from prostate cancer was lower during this time period."
But another expert tells WebMD that the best approach toward men with early-stage prostate cancer is still unclear.
The question of how to treat men with early-stage prostate cancer, or whether to treat them at all, is one of the most controversial in cancer medicine. In the U.S., most doctors favor an aggressive approach to treating localized, low-grade tumors. But in Europe, many more early-stage prostate cancer patients opt for so-called "watchful waiting," in which tumors are watched closely but not treated.
In an effort to better understand the long-term consequences of treatment that did not include cancer surgery or radiation, Albertsen and colleagues followed 767 men for at least two decades. All the men were diagnosed with low-grade prostate cancers confined to the prostate. None was treated with surgery or radiation, but many did receiveto lower testosterone levels.
The findings are published in the May 4 issue of The Journal of the American Medical Association.
Scoring Prostate Cancer
The researchers found that the risk of dying depended on the aggressiveness of the prostate cancer as measured by a rating system called the Gleason score.
Researchers found that men with a low Gleason score of 2 to 4 had a very low chance of dying during the 20-year study. Men with scores of 8 to 10 - indicating highly aggressive cancers -- had a high likelihood of death from prostate cancer. Men with scores of 5 or 6 fell in the middle.
In the U.S., where men are aggressively screened for prostate cancer, fewer large tumors -- and more and more low-grade tumors confined to the prostate -- are being diagnosed. Albertsen says more than half of newly diagnosed prostate cancers involve low-grade tumors (Gleason score of 6 or less) that have not spread outside the prostate.
He says aggressive treatment may be justifiable for otherwise healthy, younger men with these tumors. But for older patients with other health problems, aggressive treatment often makes little sense.
"For patients who are older than 65 the likelihood that these tumors will pose a threat to longevity is quite low," he says.
Cancer Treatment Decisions Not Easy
In an editorial accompanying the study, prostate cancer treatment experts Peter Gann, MD, and Misop Han, MD, of Northwestern University, wrote that the findings reinforce the importance of Gleason scoring for predicting outcomes among men with early-stage prostate cancer.
But Han tells WebMD that the optimal treatment protocol for men with localized, low-grade tumors remains unknown.
He points out that the death rate from these prostate cancers isn't zero, and, therefore, the decision on whether or not to treat isn't easy.