A study by researchers from across the U.S. has found that men with localized prostate cancer (cancer that has not spread outside the prostate) lived just as long whether or not they had prostate-removal surgery. The study is published in the July 19, 2012 issue of the New England Journal of Medicine.
The Prostate Cancer Intervention versus Observation Trial (PIVOT) enrolled 731 men with localized prostate cancer that was diagnosed through prostate specific antigen (PSA) blood tests and biopsies. About half the men were randomly assigned to receive radical prostate surgery, which removes the entire prostate gland and some of the tissue around it. The other men were assigned to the observation group. Though the men in the observation group did not undergo surgery, they were able to receive non-surgical treatment including palliative care and chemotherapy if their cancer got worse.
After 12 years of follow-up, the researchers found no real difference in the number of men who died from prostate cancer or its treatment between the 2 groups.
Researchers classified trial participants as having low-, intermediate-, or high-risk prostate cancer, based on their PSA levels and Gleason scores. They found that men in the low-risk category – those with PSA levels less than 10 and Gleason scores less than 7 – were least likely to benefit from surgery. The researchers say the study’s findings support observation over surgery for men with localized prostate cancer, especially those who have low-risk disease.
Prostate cancer often grows so slowly that many men who have it detected early throug
h PSA screening might never need treatment. One of the problems with prostate cancer screening is that it cannot determine which prostate cancers are aggressive and need treatment, and which are not likely to cause problems. As a result, most men diagnosed with prostate cancer also get active treatment. However, treatment itself can often have unpleasant, and sometimes long-lasting, side effects like incontinence and impotence.
In the study, 21.4% of men in the surgery group had a complication within 30 days after surgery, including 1 death. The most common complication was infection. Two years after the surgery, urinary incontinence and erectile dysfunction (impotence) were much more common in the surgery group than the observation group.
Active surveillance and expectant management
The treatment of prostate cancer patients through observation has evolved since this study was conducted. Until recently, observation or “watchful waiting” was widely used to mean waiting until the cancer was causing symptoms before starting any treatment. Now, it is more common to monitor the patient closely with regular PSA tests, rectal exams, and biopsies to see if the cancer is becoming more of a threat. If it is, the doctor may recommend treatment aimed at cure. This approach is more commonly referred to as “active surveillance” or “expectant management.”
The American Cancer Society recommends that men discuss the possible risks and benefits of prostate cancer screening with their doctor before deciding whether to be screened. The discussion about screening should take place at age 50 for men who are at average risk of prostate cancer and at age 45 for men who are at higher risk, including African-American men and men who have a father or brother diagnosed with prostate cancer.
Citation: Radical Prostatectomy versus Observation for Localized Prostate Cancer. Published in the July 19, 2012 issue of the New England Journal of Medicine (Vol. 367, No. 3). First author: Timothy J. Wilt, MD, MPH, Minneapolis Veterans Affairs Health Care System and University of Minnesota School of Medicine.