30-year Swedish study boosts two approaches to prostate cancer care

prostate-300x173A large, long-running study on treating prostate cancer, a leading killer of men, has supported both “watchful waiting” with most men diagnosed with the disease, and aggressive therapies — especially surgery — for patients at higher risk of the disease’s spread.

Parsing the results of this research, however, may send men to a key source of information: Their own doctors, with whom they should consult closely.

That’s because the study’s duration and the information it produced requires nuanced interpretation, depending on patients and their specifics. Just consider how news organizations differed in the headlines for their stories on the research:

Confused? Don’t be. Just understand some basics: This research stretched over 30 years and involved almost 700 men, diagnosed with cancer and randomly assigned to either monitoring, without other therapies, to see if their conditions would worsen and require more treatment or to surgery, the removal of their prostate in a procedure known as radical prostatectomy.

As U.S. News reported of the results, decades later:

By 2017, researchers found that 72 percent of surgery patients had died, versus 84 percent of men in the watchful-waiting group. The rate of death from prostate cancer, specifically, was also lower in the surgery group: 20 percent versus 31 percent. On average, the study found, surgery patients lived three years longer.

That information doesn’t, however, argue for surgery, researchers hastened to explain. For one, the men in this study had distinct characteristics: Their prostate cancer had advanced enough to be detected and diagnosed. Their disease also was localized.

The study also does not reflect medical advances, including testing for the prostate-specific antigen. It’s better known as the PSA test, and it shows an elevation of a key protein that warns of the possibility of cancer. It also is interpreted more closely now, especially in connection with a prostate biopsy that produces the so-called Gleason score indicating how abnormal or cancerous cells appear.

Swedish researchers, who published their results in the New England Journal of Medicine, noted that participants in their work who were put in their monitoring category long ago now would be treated differently: They would be checked regularly and frequently, not just waiting until they showed a major decline in condition, as had been the case in an early version of “monitored” prostate cancer treatment. They would undergo more frequent PSA tests and possibly biopsies.

Prostate cancer occurs for most men late in life, and for many, its progression will be slow, so much so that other conditions are more likely to be the cause of their death — as occurred in the Swedish study.

If the disease is localized, is diagnosed early, and shows signs that it may spread or is aggressive — as also occurred in some men in the research — it also may be beneficial to men and life-extending for them to surgically remove the prostate. Doing so, researchers found, could add just under three years to the lives of men with prostate cancer.

Here’s what else the study didn’t detail but researchers and experts hastened to note: Over-testing and over-treatment of prostate cancer is its own problem. The procedures can be invasive, painful, potentially damaging, and expensive. Surgeons once routinely responded to the disease by operating, leaving many men with lower quality of life — including problems with incontinence and sexual dysfunction. Because doctors also could not distinguish which prostate cancers are the most aggressive and lethal, and, thus may require the most aggressive treatment, some men faced repeated, painful surgery, or radiation, or chemotherapy, even after having their prostate removed and as their cancer spread.

Family history and patients’ individual circumstances matter, and men should talk at length with their doctors as they get older about prostate cancer, diagnosed in almost 165,000 cases annually and causes just under 30,000 deaths annually.

To be clear, the PSA test also now is falling into question for generalized screening, with the influential, independent, best-evidence-considering experts empaneled as the U.S. Preventive Services Task Force giving the procedure a weak C grade for whether it should be taken by men ages 55 to 69. The group downgrades the test to a D for men older than 70.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, effective, and excellent medical care. This is especially true as medical costs skyrocket, and, so, too, do the daunting complexities and uncertainties of prescription drugs, as well as medical tests and procedures. All treatments and procedures, patients should know, carry risks — and their doctors owe it to them to explain fully and in as much details as they need to make an informed decision about whether they want them or not. This is called informed consent and it is a fundamental patient right. Medical science, to its credit, has progressed so that cancer now shouldn’t be regarded only with doom and gloom. Indeed, for many, it has become a chronic, not a lethal condition.

But, as with breast cancer, prostate cancer defies current approaches in determining whether it is slow-growing and of lesser concern or if it is aggressive and lethal. Noting prostate cancer’s typical onset occurs later in life, Dr. Anthony D’Amico, chief of genitourinary radiation oncology at the Dana-Farber Cancer Institute and a professor at Harvard Medical School, both in Boston, offered a sound takeaway from the Swedish study, telling Stat about men with intermediate, risker forms of the disease: “If you live a long time, you’re likely to live longer if you get treated than if you don’t. … This study proves that if a man’s going to live 20 to 25 years and he’s got intermediate prostate cancer, he has an opportunity to save his life.”

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