Equal Death Rates Found Between Men Who Treated Prostate Cancer and Those Who Did Not
New study empowers men dianosed with the disease to make better-informed treatment diseases
A new study of men diagnosed with prostate cancer has found that the death rates of those who treated the disease and those who actively monitored it were the same.
The findings enable patients to make better-informed decisions about treatment options, including whether to treat the disease at all.
According to The New York Times (NYT), researchers followed the patients for 10 years. Men were randomly placed into three groups: those who received treatment with surgery, those treated with radiation, and those who relied instead on "active monitoring" of the disease with treatment occurring only if it progressed.
Only around one percent of patients died of the disease within 10 years of being diagnosed.
However, the probability of the cancer progressing and spreading was greater in the men who were monitored rather than treated early, and around half of those who began the study being monitored later ended up having surgery or radiation treatments.
Researchers are still following the patients, which should eventually reveal whether or not the death rate will increase for the men being monitored.
"I can counsel patients better now"
According to doctors, the findings should reassure patients that surgery and radiation are equally reasonable treatment options when the disease is in its early stages.
"I can counsel patients better now," said Dr. Freddie C. Hamdy, one of the study leaders at the University of Oxford. "I can tell them very precisely, 'Look, your risk of dying from cancer is very, very small. If you receive treatment you will get some benefit. It will reduce the disease from growing outside your prostate, but these are exactly the side effects you might expect.'"
Although patients being monitored are not receiving treatment, they are not doing nothing about the disease. They make regular visits to clinics involving physical prostate exams and undergo periodic biopsies as well as blood testing for prostate-specific antigen (PSA), which can be an indicator of the worsening of the disease. Somewhere between 40 and 50 percent of men in the U.S. diagnosed with early prostate cancer now choose active monitoring over treatment.
This was the first study to include detailed patient information about treatment side effects.
Patients whose prostates were removed surgically were the most likely to experience lingering impotence and urinary incontinence. Men who underwent radiation treatment experienced bowel problems after six months of the treatment, though those issues usually improved; however, they did not report urinary incontinence. Radiation also diminished sexual function, but this also somewhat recovered.
No differences were reported among the groups regarding anxiety, depression, or how the patients felt that their health affected their quality of life.
According to Dr. Peter T. Scardino, who was not involved in the study but who works as a prostate surgeon and the chairman of the Memorial Sloan Kettering Cancer Center Department of Surgery, the findings are important due to the relative dearth of previous data comparing surgery, radiation, and active monitoring in men diagnosed with early prostate cancer.
Dr. Scardino also believes that the findings confirm that active monitoring can be a valuable approach to take for many patients and that it would be an appropriate option for one third to one half of men who have early prostate cancers. He said that only one third of these patients would need actual cancer treatment within a period of 10 years.
However, he also emphasized that the active monitoring must be done on a regular basis and very carefully for the rest of the life of the patient. He added that the study sends an important message that early-stage prostate cancer is not an emergency, so patients have time to figure out the best approach to take.
In 2012—the most recent year data were gathered by the International Agency for Research on Cancer—there were 1.1 million cases of prostate cancer and 307,000 deaths from the disease across the globe. Around 181,000 cases and 26,000 deaths are expected to occur in the U.S. in 2016. The average age of men diagnosed with the disease in the U.S. is 66, with the cancer rarely appearing in men under 40. The American Cancer Center states that most men who have prostate cancer do not die from it.
While the disease often progresses at a very slow rate, it sometimes grows quickly. There are some cases that may be deadly, but tests cannot always determine which those cases are. This leaves many patients uncertain about the best way to approach the disease, especially because of treatment side effects such as bowel, bladder, and sexual problems.
The United States Preventive Services Task Force, an independent panel of experts chosen by the government, recommended in 2012 that patients should not undergo routine screening for the disease using the PSA test. According to the panel, such screening finds many tumors that may never do any harm, and it leads too many patients into unnecessary surgery or radiation treatments with their accompanying side effects.
This was the problem the researchers set out to address. They followed 1,643 men in Britain aged 50 to 69 who had been diagnosed with an early-state prostate cancer that had been discovered using routine PSA testing followed by a biopsy in the event that the PSA numbers were abnormal. All the cancers were localized, i.e. they were located only in the prostate and had not yet spread to any nearby tissue or other organs.
The patients involved in the study all had PSA measurements of three or above, and roughly three quarters of the patients had a Gleason score—a measure of aggressiveness—of six. Gleason scores in cancers range from six to 10, with the aggressiveness getting worse as the scores go up.
At this point, the men were randomly placed in one of three groups: one third treated the disease with surgery, one third treated it with radiation, and one third relied on active monitoring.
Although the death rates were the same, more men in the active monitoring group experienced progression of the cancer. Thirty-three of these experienced the spread of the disease to distant parts of the body, while only 13 in the surgery group and 16 in the radiation group had this experience. These differences were statistically significant. There were also 112 cases of progression to nearby tissue outside the prostate in the monitoring group, in comparison with 46 each in the other two groups.
And as time wore on, more and more men in the monitoring group received some kind of treatment, though Dr. Hamdy said that not all of these actually needed it.
"We know that 80 percent of them had not shown signs of progression," he said, then added that anxiety in either the patients or their doctors or a suspicion of progression of the disease may have changed their minds about treatment.
One patient who switched was Robert Boulton, a 76-year-old retired maker of rubber gloves. He made the switch to radiation when his PSA went up after four years. According to him, two of his doctors recommended the treatment and one was against it, so he decided to follow the advice of the majority. His only side effect, he said, was "man boobs," swelling that occurred in the breast area due to the hormonal treatment administered alongside radiation.
"I'm feeling fine now," he added. "No problems."
Douglad Collett, age 73, has stayed in the active monitoring group. He said that when he was first diagnosed, he wanted to get rid of the disease immediately. However, when he learned more about it and the potential side effects of receiving treatment, waiting seemed more sensible. He was relieved to be placed in the monitoring group.
He knows that the cancer may progress, he said, and he will likely treat it with radiation if that happens. Right now, however, he says that he is "fit as a flea."