Prostate Cancer: Watchful Waiting Versus Surgery (Prostatectomy)

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As I have observed in previous columns, the optimal management of patients with prostate cancer is the subject of ongoing debate among prostate cancer experts. Most of the accepted treatments for prostate cancer carry a considerable risk of long-term complications, and determining precisely which patients will benefit from aggressive treatment, versus those who are not likely to benefit, has proven to be a very difficult clinical problem.

We know that for many men, and elderly men in particular, prostate cancer often grows very slowly, and often does not result in any major complications (including death) either with or without treatment. On the other hand, more than 32,000 American men died from more aggressive forms of prostate cancer in 2010. For selected men who develop less aggressive, indolent, forms of prostate cancer, “watchful waiting” may be more appropriate than subjecting these men to aggressive surgery or radiation treatment for their cancers. At the same time, men with potentially more aggressive cancers should, obviously, consider prostatectomy (surgical removal of the prostate gland) or radiation therapy to treat their disease. Unfortunately, we are still not able to predict how aggressively any individual patient’s prostate cancer will behave over time, nor are we able to accurately predict whether or not some other cause of death is more likely to occur rather than death due to prostate cancer.This inability to accurately predict the future likelihood of dying from prostate cancer, either with or without treatment, for individual patients has made it very difficult to accurately advise patients whether or not they might be candidates for “watchful waiting” rather than recommending aggressive prostate cancer treatment. However, a newly published prospective, randomized clinical research trial from Sweden, which appears in this week’s New England Journal of Medicine, may help doctors and their patients to make a more informed decision regarding the management of early-stage prostate cancer.

In this study, 695 men with early-stage prostate cancer were randomly assigned either to “watchful waiting” or radical prostate surgery (prostatectomy). These two groups of men were then followed for an average of about 13 years, and the clinical outcomes in each group, including death due to prostate cancer, were compared. Among the men in the “watchful waiting” group, the estimated risk of death due to prostate cancer was 21 percent, as compared to a 15 percent risk of death due to prostate cancer among the men who underwent prostatectomy. This difference in cancer-specific survival was equivalent to a 38 percent reduction in the relative risk of dying from prostate cancer with prostatectomy, and an absolute reduction in the risk of death of more than 6 percent.

The findings of this clinical research study are similar to other recent studies that have also linked prostate cancer treatment, in otherwise healthy men, with improved survival when compared to “watchful waiting” alone, and especially for men with early-stage prostate cancer that is still confined within the prostate gland itself. While “watchful waiting” may still be appropriate for some very elderly or very ill patients, the findings of this study, and others like it, still appear to favor active treatment for early prostate cancer in most otherwise healthy men.

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Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity

Dr. Wascher is an oncologic surgeon, professor of surgery, cancer researcher, oncology consultant, and a widely published author

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