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Careful Monitoring, Radiation or Surgery — What’s Better for Men with Prostate Cancer?

November 23, 2016

Doctors will diagnose more than 180,000 new cases of prostate cancer this year, but for many patients deciding what treatment approach to take — and what side effects they can endure — is often the most difficult choice.

A new 10-year study highlights the treatment conundrum many men face. The study, published in the New England Journal of Medicine, found that prostate cancer death rates were about the same regardless of whether a patient chose ongoing monitoring or underwent radiation or prostate removal.

However, healthy men who chose what researchers refer to as “watchful waiting” still faced a serious risk: their cancer was twice as likely to spread over the 10 years researchers tracked. This suggests that men who are otherwise healthy are in more jeopardy if they wait to treat the cancer than if they proceed with surgery or radiation.

Researchers also examined what treatment was best for men with localized prostate cancer. They randomly assigned 1,600 men with prostate cancer to one of the three different treatment approaches. A portion of the group underwent ongoing monitoring, while others either underwent radiation or prostate removal. All the men were tracked for a median time of 10 years. Researchers said survival rates were good across all three treatments — at 99 percent regardless of the assigned treatment.

However, the critical difference was whether the cancer spread. The cancer spread in about 6 percent of the men who underwent active monitoring, about 2 percent of those who had surgery and in about 3 percent of men who had radiation therapy. Researchers found no apparent differences in prostate cancer death rates across the three treatments. 

While death rates appear to be the same, the trial will need longer term follow-up. This is important particularly for younger patients. Many of the people in the trial were older with other health issues and may have succumb to those rather than prostate cancer. This can affect the long-term outcomes in the study.

It’s still not entirely clear what the best approach is for low-to-immediate risk prostate cancer. Each patient will have to weigh the risks and benefits of each treatment in consultation with his doctor to decide the best approach based on his prognosis. Dr. Anthony D'Amico, a professor at Harvard Medical School who an editorial that accompanied the studies, suggests that men with other health issues who are undergoing active monitoring continue to do so because getting treatment won’t significantly lower their risk of dying of prostate cancer. However, men who are healthy and likely to live more than 10 years should get treatment, since the risk of the cancer spreading increases with active monitoring.

Some men with early-stage prostate cancer opt for active monitoring because of the risks associated with treatment. Prostate removal can affect sexual function and cause bladder control issue, while radiation therapy can lead to bowel issues and sexual side effects. Some of these issues occur during the first six months of treatment, but they still may be evident throughout the entire course of treatment and during follow-ups after treatment.

Currently, prostate cancer best practices dictate that a patient meet with multiple providers prior to making a final decision. At the Cancer Center, we will usually try to have patients meet a surgeon, medical oncologist, and radiation oncologist so the patient can be as informed as possible. This is in no small part due to the severity of prostate cancer itself. The SEER registry analyzes annual statistics of prostate cancer and emphasizes that not all cases are alike. There are different pathologies, different Gleeson scores, and different patterns of spread that weren’t covered in this particular study. Therefore, it is all the more important to have an open dialogue with providers to make sure people are as informed as they need to be.

Though the idea of simply monitoring a cancer may be appealing, I urge men to weigh these considerations — along with the potential for the cancer to spread — before you decide which treatment option is right for you.

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