If you would like to subscribe to this blog, click this link and subscribe on the left of the home page. A new article appeared this week with further fuel for those on the side of intervention (and by implication, pro-screening). Let’s remember before we get started, that the two largest trials of screening vs not screening did not show a very big impact, if any, on finding and treating prostate cancer. Moreover, that treatment is toxic to many men who may not have needed it.
The study is about men who HAVE prostate cancer and are randomized to surveillance versus surgery. This is different from the conundrum of screening. These guys were “caught” by whatever means via a biopsy that found cancer. In the NEJM article from Scandinavia, 695 men diagnosed between 1989-99 were randomized to watchful waiting vs. prostatectomy. Their mean age was 65 and 88% of the men had palpable tumors, different from the more common T1c (PSA only) detected in the current era. Here’s a sobering fact: by 2012, 64% of them were dead. Argh….the end is near!
What we care about is their quality of life and how much of that death was attributable to prostate cancer. We are all going to die of something….just don’t torture us please. As regards death, 63/347 (18%) men in the prostatectomy group died from prostate cancer while it was 99/348 (28%) of the surveillance group. However, the overall death rate was 56% vs 69%, so more men in each group died of something else. There are many kinds of additional analyses in the study, including the death rate from low, intermediate, and high risk cancers, effects of age, time on hormonal therapy, and so forth. The benefit of early surgery seems to be greatest in men under 65 with intermediate risk (Gleason 7) cancers. As regards quality of life, more men had metastases in the surveillance group and as the authors state, “The cumulative incidence of the use of androgen-deprivation therapy at 18 years was 42.5% in the radical-prostatectomy group and 67.4% in the watchful-waiting group (a difference of 25.0 percentage points; 95% CI, 17.7 to 32.3)” My conclusion is that men who are younger (you pick the age…) and have higher grade tumors (any finding of Gleason 4) are probably better off electing treatment than watching. It is certainly possible that surgery or radiation therapy are equally good choices, but that is not addressed here.
My conclusion is that men should still think carefully about stopping screening as they near 70 unless their parents lived into their late 80’s or 90’s and they enjoy superb health. If they participate in screening and are found to have a Gleason 7 or higher cancer, they should be treated. Those thoughts are not new. The studies also support treatment for lower risk patients, but the preservation of quality of life (potency, continence) and lower impact on the development of metastases or dying, make the decision much tougher.