Prostate Cancer: Early Surgery or Watchful Waiting?

Study Shows Early Surgery Cuts Deaths From Low-Risk Prostate Cancer

By Daniel J. DeNoon
WebMD Health News

Reviewed by Laura J. Martin, MD

May 4, 2011 -- Fifteen-year results from a Swedish study show that early prostate surgery cuts deaths in under-65 men with "low-risk" prostate tumors -- but for today's men, the definition of "low risk" has changed.

The study of 695 men with early prostate cancer assigned half the men to immediate surgery -- prostatectomy -- and half to watchful waiting. The first results, reported in 2002, showed that early surgery improved survival.

In watchful waiting, patients are not treated but monitored closely to see if there is any progression of the disease.

Now, 15 years after the study began, it's clear that men who underwent early surgery cut their risk of death from prostate cancer by 38%.

However, only men under age 65 saw this benefit. Early surgery did not significantly improve survival in men diagnosed with prostate cancer after age 65, notes Anna Bill-Axelson, MD, PhD, lead author of the report in the May 5 issue of the New England Journal of Medicine.

"What we see is that surgery reduces prostate cancer deaths, but that not all patients need to undergo surgery," Bill-Axelson tells WebMD. "It depends on age, on the presence of other medical conditions, on patient preference, and on how the tumor looks. You cannot generalize and say everybody needs to undergo surgery."

The study showed that:

  • Overall, 15 men had to undergo prostate surgery to save one death from prostate cancer. For men under age 65, seven had to be treated to prevent one prostate cancer death.
  • Men whose tumors had broken through the prostate capsule had a much higher risk of death than did those with tumors that remained inside the capsule.
  • 63% of the men assigned to watchful waiting and 40% of the men assigned to prostatectomy needed androgen-deprivation therapy, which has serious side effects that include sexual dysfunction, fatigue, and risk factors for diabetes and heart disease.
  • More men in the watchful waiting group than in the prostate surgery group died from causes other than prostate cancer but with spreading prostate cancer that would likely have been fatal.

Prostatectomy for Low-Risk Prostate Cancer?

Possibly the most important study finding is that among these younger men, surgery improved survival even in those with prostate tumors considered to be low risk -- by the standards of the decade 1989-1999.

"When we say the low-risk group benefits from surgery, it is not as we would define a low-risk group by today's standards," Bill-Axelson says. "It is important that people don't panic and all go for surgery. It is important to have people closely watched and to undergo surgery when necessary."

There are degrees of "low risk" for prostate tumors, says prostate cancer expert Matthew R. Smith, MD, PhD, director of the genitourinary malignancies program at Massachusetts General Hospital. Smith's editorial accompanies the Bill-Axelson study in the New England Journal of Medicine.

Smith notes that in the Swedish study, 88% of the men had tumors that could be felt on a rectal exam, and only about 5% had their cancer detected via PSA screening tests. In the U.S. today, fewer than half of men diagnosed with prostate cancer have tumors that can be felt on a rectal exam, and most cancers are detected via PSA screening.

This means that today, most prostate cancers are diagnosed seven to 10 years earlier than they were when the men in the Swedish study were diagnosed.

"Since these cancers were not well represented in the Scandinavian study, we cannot generalize from this to say men diagnosed with low-grade cancer today would derive the same benefit. We still don't know if we have to treat all of those men," Smith tells WebMD.

But Smith agrees with Bill-Axelson that immediate treatment isn't necessary for all of these men. When a patient's biopsy shows that a prostate tumor has a low grade, and that tumor volume is small, the patient is a likely candidate for active surveillance.

For some doctors, "active surveillance" differs a bit from "watchful waiting" in that the tumor is carefully monitored, with repeat biopsies as necessary, so that a patient gets appropriate treatment as soon as the cancer progresses -- but well before it becomes a high-risk tumor.

"We do enthusiastically recommend active surveillance in carefully selected patients," Smith says. "This is not to say, 'Have surgery or go off on your own.' It is actively monitoring men with low-risk disease and selectively intervening when there is sufficient information about the cancer to justify treatment."

Men worried about prostate cancer and the doctors who treat the disease would love to have a lot more information about prostate cancer, a better screening test, and treatments with fewer side effects. But Smith insists that treatment plans can be optimized for each patient.

"We can individualize patient decisions," Smith says. "We may not have all the information we need, but we can still make good decisions."


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SOURCES: Bill-Axelson, A. The New England Journal of Medicine, May 5, 2011; vol 364: pp 1708-1717.Smith, M.R. The New England Journal of Medicine, May 5, 2011; vol 364: pp 1770-1772.Anna Bill-Axelson, MD, PhD, department of urology, Uppsala University hospital; division of clinical cancer epidemiology, Karolinska Institute, Stockholm.Matthew R. Smith, MD, PhD, professor of medicine, Harvard Medical School; program director, genitourinary oncology, Massachusetts General Hospital, Boston.©2011 WebMD, LLC. All Rights Reserved.