Prostate Cancer: Cut or Wait?

By Christine Gorman

Imagine an experiment in which a few hundred women with breast cancer are divided into two groups. Patients in one group have their tumors surgically removed, while those in the other wait patiently, keeping a close eye on the progress of their disease, and are treated only if their cancer starts to spread. Sound barbaric? Substitute prostate cancer for breast cancer, and that is pretty much what 700 Scandinavian men in the early stages of prostate cancer agreed to. The results, published in the New England Journal of Medicine last week, showed that the men who underwent surgery were half as likely to die of prostate cancer as those in the "watchful waiting" group.

Predictable as that conclusion might seem, doctors consider the study a landmark. Physicians have debated for years how aggressively they should treat cancer of the prostate. Because the disease tends to be very slow growing, many more men will die with prostate cancer than from it. Nobody wants to undergo surgery or radiation treatment if that can be avoided, especially because in the case of prostate cancer the side effects typically include impotence and incontinence. On the other hand, you don't want to die of prostate cancer if you can help it. If the cancer spreads to the bones, it can be excruciatingly painful, and once it spreads, death is often unavoidable.

What does this mean for you? The New England Journal study probably tilts the equation toward treatment--especially if you have early-stage prostate cancer and expect to live 10 more years. (On average, it may take such a tumor, if it recurs, a decade or more after treatment to cause death.) Watchful waiting probably makes more sense for older men, particularly if they are frail.

As with any other complex medical study, however, there are some tricky caveats. First off, prostate cancer is treated differently in Scandinavia, where watchful waiting is the norm, than it is in the U.S. Moreover, because Scandinavian men are not screened for prostate cancer as aggressively as American men, they tend to be older when they get their first diagnosis. And though the men in the surgery group were less likely to die of prostate cancer than the watchful waiters, it turned out there was no statistically significant difference in how long they lived.

Such a result is not as contradictory as it sounds. Given that follow-up averaged just over six years, it's quite possible that the study didn't last long enough to show an appreciable difference in the two groups' death rates. Even if it turns out that the men in the surgery group didn't live any longer and were merely spared death from prostate cancer, that's quite an accomplishment, says Dr. Patrick Walsh at the Johns Hopkins Medical Institutions in Baltimore, Md., who invented a widely used nerve-sparing prostate surgery. "If you had a choice of dying of prostate cancer vs. dying of a heart attack," he says, "you'd pick dying of a heart attack."

Still unknown is whether screening someone for prostate cancer with blood tests that look for prostate-specific antigen (PSA) reduces the risk of death from prostate cancer. Studies designed to answer that question are under way. Until then, you will have to gather and weigh all the information you can when deciding how, or even whether, to treat prostate cancer.

For more information, search for "prostate" at cancer.gov