Watchful Waiting or Surgery? A Tough Call for Localized Prostate Cancer
Men who are diagnosed with prostate cancer face a daunting decision about their treatment. Their options include radiation therapy, hormonal therapy, surgery to remove all or part of the prostate (and possibly some lymph nodes), and watchful waiting, in which doctors monitor tumor growth and eventually make decisions about appropriate treatment. Which option is best depends on age, overall health, the stage of cancer, and personal quality of life goals. For instance, prostate removal surgery carries the risk of erectile dysfunction and urinary leakage. In the end, some prostate cancers never grow large enough to kill the patient before he dies of some other cause.
In the midst of the debate over how to treat early, localized prostate cancers, two articles in the September 12, 2002 New England Journal of Medicine offer some clues to guide treatment decisions. One article suggests that radical prostatectomy may reduce deaths due to prostate cancer when compared with watchful waiting. However, the surgery did not reduce overall mortality rates, meaning deaths from all causes. The second article reports that although erectile dysfunction and urinary leakage are more common among men who undergo radical prostatectomy, the overall quality of life seems to be similar among both groups.
About the Study
Scandinavian researchers conducted two studies on the same group of men between 1989 and 1999.
In the first study, the researchers enrolled 695 men under the age of 75 with localized prostate cancer (prostate cancer that had not spread beyond the prostate gland). Patients were excluded from this study if they had other cancers, signs of urinary obstruction, prostate-specific antigen (PSA) levels of 50 nanograms per milliliter or higher (normal is < 4 nanograms per milliliter), or bone scans indicating the cancer had spread beyond the prostate gland.
Patients were randomly assigned either to undergo radical prostatectomy (surgery to remove the prostate) or to be treated according to a watchful waiting plan. All participants underwent follow-up exams twice yearly for the first two years and annually for the remaining years of the study. After an average or 6 years of follow-up on each participant, researchers compared deaths due to prostate cancer and deaths due to all causes between the radical prostatectomy and watchful waiting groups.
For the second study, researchers contacted the 376 men who had entered the study between 1989 and 1996. They mailed the 356 men who agreed to participate in their survey a questionnaire asking about their sexual potency, urinary function, and overall quality of life since they either had the surgery or began the watchful waiting phase. Researchers compared erectile dysfunction, urinary leakage, urinary obstruction, and quality of life among men who had undergone radical prostatectomy with those who were assigned to watchful waiting.
Men who underwent radical prostatectomy were 50% less likely to die of prostate cancer than men assigned to watchful waiting. However, deaths from all causes did not differ between the two groups, indicating that the overall survival rate was similar in both groups.
With regard to side effects and quality of life, 80% of men in the surgery group reported erectile dysfunction compared with 45% in the watchful waiting group. Urinary leakage was also more common in the surgery group—49% versus 21%. On the other hand, urinary obstruction was more common in the watchful waiting group—44% versus 28%. Quality of life, however, was similar between the two groups.
Although these studies appear to suggest some advantages to radical prostatectomy over watchful waiting for localized prostate cancer, they have their limitations. First, 75% of men in this study were diagnosed based on physical examination of the prostate in which the doctor could feel the tumor. But most prostate cancers are diagnosed when elevated PSA levels lead doctors to test a sample of prostate tissue for cancer cells. These findings may not apply to such cases detected so early. Second, it’s not clear whether surgeons in this study performed nerve-sparing surgery, which reduces sexual and urinary function complications. Third, the surveys regarding quality of life and sexual and urinary side effects were not conducted at the start of the study. For this reason, researchers were not able to compare survey scores from before and after surgery or watchful waiting.
How Does This Affect You?
Although these results don’t make treatment decisions a whole lot easier for men diagnosed with prostate cancer, they do provide some helpful information for men to consider when discussing treatment options with their physicians. On the positive side, the results suggest that men under age 75 with localized prostate cancer may benefit from surgery. On the negative side, the findings suggest that erectile dysfunction and urinary leakage are more of a concern for men who opt for surgery. However, problems with urinary blockage were more common in the men who did not have surgery, suggesting that growth of the prostate tumor presents its own urinary problems. This may at least partially account for the fact that quality of life did not differ in the two groups. But probably the most significant finding was that overall mortality was no different between prostatectomy and watchful waiting, suggesting that patients who underwent surgery were at higher risk of dying from other causes.
In an editorial accompanying the research articles, Patrick C. Walsh, MD, of Johns Hopkins Hospital in Baltimore, Maryland explains that no prostate cancer treatment option is without risks to quality of life. He stresses that a patient’s best treatment option is heavily dependent on factors such as age, overall health, personal quality of life requirements, and whether the cancer has spread to other parts of the body.
National Cancer Institute
American Cancer Society
Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. NEJM. 2002;347:781-789.
Steineck G, Helgesen F, Adolfsson J, et al. Quality of life after radical prostatectomy or watchful waiting. NEJM. 2002;347:790-796.
Walsh PC. Surgery and the reduction of mortality from prostate cancer. NEJM. 2002;347:839-840.
Last reviewed Sep 13, 2002 by
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