Prostate cancer has always been an exception in the cancer field. Unlike most forms of the disease, it’s slow-growing, and while it can be fatal, in most cases it’s indolent enough that men are more likely to die of other causes than the cancer itself.
So screening for prostate cancer, as well as figuring out the best ways to treat it, has triggered vigorous debate and conflicting opinions in recent years. Doctors have raised concerns about the use of PSA screening, since it has led to some over-treatment of prostate cancer and caused more side effects—including sexual dysfunction and urinary problems. Some experts advocate a hands-off approach of so-called "active surveillance" rather than treating it immediate with surgery or radiation, but there's confusion about what such monitoring means—it's not just doing nothing. Instead, it involves regular testing and tracking of the cancer to ensure it's not starting to grow too rapidly. Still, the studies to indicate that a man should opt for one option over the other has been wanting.
Now, a new study published in New England Journal of Medicine may change that. It’s the first to compare active surveillance, surgery and radiation in a group of men whose PSA tests indicate their levels are a little high. The 1,643 men agreed to be randomly assigned to one of the three treatments, and to be followed for 10 years.
Among all three groups, the death rate from prostate cancer was low, at about 1%, and nearly identical. That suggests that regardless of which treatment option men chose, their likelihood of dying of prostate cancer was the same. Considering the side effects and adverse results of prostate cancer treatment, these new results may help some men make the choice to forgo aggressive treatment in lieu of less invasive options.
“I hope this helps patients to be better informed and to not rush into treatment decisions,” says Dr. Freddie Hamdy, professor of surgery and urology at University of Oxford and lead author of the study. “In the end, we’re giving them good news. If you have this kind of cancer, you’re going to have to wait a long time for that to damage your health and affect your mortality in any significant way.”
There were some observed differences in the men. The active surveillance group had twice as much progression of their prostate cancer, including metastases to other tissues including bone and lymph nodes, than men who were assigned to surgery or radiation. But more cancer doesn't always mean higher risk of death, as this study found. That’s not easy to get your head around, and among men who saw their cancers grow, nearly 55% decided to get surgery or radiation and dropped out of the active monitoring group.
“These results tell me that active surveillance is still a fairly safe way to go,” says Dr. David Penson, chair of urologic surgery at Vanderbilt Medical Center and spokesperson for the American Urological Association. “But it underscores the fact that we are going to have to select the right patient.”
The aggressiveness of the prostate cancer, how advanced the disease is, as well as a man’s overall health status are likely all factors that will help determine whether active monitoring is the right option. For older men who may be unhealthy and already suffering from other health issues, for example, the findings should reassure them that they likely won’t need to take immediate action if they are diagnosed with prostate cancer. They can choose active monitoring since they are more likely to die of other causes.
But for younger, healthy men diagnosed with the disease, the choice might be harder. Because of their age, over time their cancer is more likely to spread, and they will therefore more likely need to treat it with hormonal therapy after surgery or radiation. And because they are healthy, that would significantly alter their quality of life, compared to men who might have chosen surgery or radiation earlier, not had the cancer spread, and only needed temporary hormone therapy.
How men will interpret these results will clearly depend on their individual health status, and their own tolerance for side effects. But these findings at least will provide them with more information to make treatment decisions with a little more confidence.