A study involving more than 80,000 men followed for 10 years gives some important clues, but no final answers, on what patients with a diagnosis of prostate cancer should do. It’s long been a puzzle because prostate cancer is one of the most common and deadliest cancers for men, yet in many cases it’s so slow to grow that men die with, not from, prostate cancer.
Here’s the bottom line, which the researchers emphasized needs to be continued for an even longer time for its findings to be more authoritative:
At a median of 10 years, prostate-cancer–specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments. Surgery and radiotherapy were associated with lower incidences of disease progression and metastases than was active monitoring.
Before digging in to what this means, besides the good news that prostate cancer in its first decade after detection need not be as fearsome as some have portrayed it, it’s important to hit on some basics about the disease.
Medical science, unfortunately, has not advanced so doctors can tell which prostate cancers are the most lethal and thus require a big-gun response. The age when men are diagnosed with the disease increasingly has become key in how patients and doctors respond; it is rare in men 40 or younger, 6 in 10 cases are detected in men 65 and older. Doctors, over time, have under- and over-treated prostate cancer. The results have been decidedly mixed.
Even in optimal circumstance, prostate cancer surgery and radiation treatments have caused severe side effects, including sexual dysfunction, and bowel and bladder incontinence that can hurt quality of life; the treatments can be painful and invasive. On the other hand, forgoing treatment can allow the disease to grow and spread with bad results.
Campaigns to get more men to undergo existing ways to detect the disease, especially the prostate-specific antigen (PSA) test, have proven unproductive and controversial. A blue-chip, governmental health advisory group has pulled back from the one-time guidance that men should undergo the PSA test annually, though the exam continues to be promoted in questionable fashion at mass screenings at public health fairs.
Along with their shifts in thinking about PSA tests, researchers and clinicians have looked at available data and have consulted carefully with patients to see which prostate cancer treatment approaches work best. They are considering patients’ age, family history, condition, prospective survival times, but also cost, and quality of life. Doctors and patients have pursued “watchful waiting,” monitoring detected prostate cancer but not attacking it aggressively as has been tried before.
The new research offers support to varied approaches, including “watchful waiting,” depending on individual patients’ situations.
To their credit, the media reporting on this study have done so with care−and men with prostate cancer should discuss this research with their doctors, because it demands, for example, a thoughtful approach to statistical data and consideration of such issues as relative versus absolute risk.
This research again shows how challenging it can be to advance medical science: even as extensive as this study was, the number of patients in it totaled only about 1,700 with early diagnosis of prostate cancer, who were then assigned randomly to each of three categories of care, monitoring, surgery, or radiation.
In a decade, here is how is the prostate cancer deaths tallied by treatment: eight among the monitored, five who had surgery, and four who had radiation. With small numbers like that, it’s no wonder the researchers found no statistically meaningful difference between the groups in overall survival.
Men with a family history of cancer and especially prostate cancer may talk with their doctors and decide on more robust treatment; those with cancers that start to spread also may undergo different treatment.
As the Washington Post noted of men in the study: “Those who underwent surgery or radiation cut in half the risk that their disease would spread to bones and lymph nodes, compared with those who were simply monitored.” But as the study notes: “Men with newly diagnosed, localized prostate cancer need to consider the critical trade-off between the short-term and long-term effects of radical treatments on urinary, bowel and sexual function and the higher risks of disease progression” that comes with monitoring.
A key driver in prostate cancer care, of course, is cost, which, for an uninsured man might go anywhere from $10,000 to $135,000, depending on the hospital and procedures. I’ve written before about the huge stress that the skyrocketing cost of cancer care can create for patients and their families.
With the many approaches to prostate cancer in particular, physicians−even more than ever for their patients’ sake−need to take huge care in diagnosis and monitoring. A hurried pathologist’s missed diagnosis on whether a patient’s monitored prostate cancer is spreading may merit a legal claim such as a malpractice lawsuit. That’s especially true because that ailing man and his loved ones may be bearing serious consequence.