Forgoing Treatment Makes No Difference in Early Prostate Cancer

A recent report in the wall street journal confirms that a study could reassure men wrestling with early prostate cancer: Whether they opt for radiation, surgery or no treatment at all, their risk of dying of the disease in 10 years is low—less than 1%—and the treatment makes no significant difference.
Undergoing surgery or radiation lowered the risk the cancer would spread, by more than 50% compared with simply monitoring it, the study found, but that didn’t result in a significantly higher risk of death over 10 years because prostate cancers grow slowly.
“It may be that at 15 or 20 years there is a difference in survival. We need more time to get to the final chapter,” said Freddie Hamdy, a professor of urology at the University of Oxford and chief investigator of the study, published Wednesday in the New England Journal of Medicine.
Prostate cancer is the second-most-common cancer among men, after skin cancer; an estimated 180,890 U.S. men will be diagnosed with it this year, and 26,120 are expected to die from it.
Yet many patients are confused about how and whether to treat it. Radiologists and surgeons have battled for years over which treatment is better. There is increasing support for simply monitoring early-stage prostate cancers instead, because they tend to be slow-growing and treatment can bring unpleasant side effect.
The new study, funded by the U.K.’s National Institute for Health Research, is unusual because patients—1,643 British men aged 50 to 69 diagnosed with localized prostate cancer between 1999 and 2009—agreed to be randomly assigned to a treatment option. About half of those assigned to active monitoring switched to surgery or radiation by 10 years—mostly because they were anxious about leaving their cancer untreated, not because it had spread, according to Dr. Hamdy.
Overall, the rate of cancer progression remained low—at roughly 1 in 5 men in the active-monitoring group, compared with 1 in 10 who had either surgery or radiation.
A second study compared patient-reported side effects for all three options and found significant differences. Six months after treatment, about half of the men who had surgery said they wore pads due to urinary incontinence. While many regained function, 17% still wore pads after six years, compared with 4% in the radiology group.
At six months, 88% of men who had surgery and 78% who had radiation reported sexual problems. By six years, more men in the radiation group recovered sexual function, but the radiation group also reported more bowel problems.
Men in the active-monitoring group reported some loss of sexual and urinary function—mainly due to aging and because about half eventually opted for treatment, according to Jenny Donovan, a professor of social medicine at the University of Bristol, and a co-investigator.
“All these treatments have a role, and because the survival rate is so good—99%—men don’t need to rush to decide what strategy to take. They can consider what they want most of their lives.” she said in an interview.
However, the new studies aren’t likely to end the prostate-cancer debates any time soon.
In an accompanying editorial, Anthony D’Amico, a radiologist with Dana-Farber Cancer Institute in Boston, noted that men who opt to monitor their cancer could end up with more side effects if the cancer spread and required more aggressive treatment later.
But Otis Brawley, chief medical officer of the American Cancer Society, said the new studies add to mounting evidence that men with localized prostate cancer can safely opt to postpone treatment.
“The side effects make me feel even stronger than we need to be practicing more surveillance and observation,” he said.

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