Prostate Surgery May be Better Choice for Younger Men

Radical prostatectomy for prostate cancer reduced risk of death compared to watchful waiting

(RxWiki News) There's some debate on how to handle early prostate cancer. While some doctors recommend surgery to remove the entire prostate, others advise waiting and monitoring to see if the disease advances.

A research team recently tested which of these approaches would benefit early prostate cancer patients the most.

These researchers found a significant reduction in death after radical prostatectomy (prostate removal) in men with localized cancer. This effect was limited to men under age 65.

"See your doctor for prostate cancer screening."

Anna Bill-Axelson, MD, PhD, from the Department of Urology at Uppsala University Hospital in Sweden, and Lars Holmberg, MD, PhD, from the Regional Cancer Center Uppsala Orebro, Uppsala University Hospital and King’s College London, England, led this research.

Over 230,000 men in the US will be diagnosed with prostate cancer this year. How to treat early prostate cancer is a subject debated by doctors. Studies have shown the value of both radical prostatectomy (removing the entire prostate gland) and of monitoring the disease with watchful waiting.

Dr. Bill-Axelson and colleagues recruited 695 men with early prostate cancer into their study. They divided these patients into two groups. One group had radical prostatectomies and one group was assigned to observation without treatment.

Study participants were followed every six months for two years, then annually. Physical and rectal examinations were done to check for any masses that might be cancer. Bone scans were done to check for cancer metastases, signs that cancer has spread. Patients were followed for an average of slightly more than 13 years.

Over the course of the study, 200 men in the surgery group died and 247 men in the watchful waiting group died.

Analysis of the results showed that the relative risk of death from any cause was decreased by 29 percent in the group receiving surgery compared to watchful waiting. The relative risk of death from prostate cancer was decreased by 44 percent among those who received surgery compared to the watchful waiting group.

Relative risk of cancer metastases fell by 43 percent in the radical prostatectomy group compared to the watchful waiting group.

When the effects were examined only among men under age 65, the results showed a significant reduction in death risk in the group receiving surgery versus the watchful waiting group.

There was a 25 percent decrease in death, a 16 percent decrease in prostate cancer death and a 16 percent decrease in risk of metastases among men under age 65 in the prostatectomy group compared to men of similar age in the watchful waiting group.

The researchers saw a decrease in cancer metastases risk among men over age 65 who had prostate surgery.

At a 12-year follow-up, erectile dysfunction was reported by 80 to 84 percent of men in both groups. Leakage of urine was reported by 41 percent of the radical prostatectomy group and 11 percent of the watchful waiting group.

While these results suggest that young men with early prostate cancer may benefit from surgery, the authors of this study wrote that "the large proportion of long-term survivors in the watchful waiting group who never required palliative treatment provide support for active surveillance as an alternative in adequately selected groups.”

Co-author Jennifer Rider, assistant professor in the Department of Epidemiology at HSPH and assistant professor of medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, said in a press release, "The latest results from the SPCG-4 trial indicate that surgery can not only improve survival, especially in men diagnosed at a younger age or with intermediate-risk disease, but also that surgery can reduce the burden of disease in terms of development of metastases and the need for palliative treatment."

"However, a large proportion of men in the trial still alive at 18 years did not require initial surgery or any subsequent therapy, pointing to the potential benefits of active surveillance strategies to limit overtreatment," she said.

"This publication represents another update of the Scandinavian localized prostate trial. This trial continues to focus on a survival advantage of radical prostatectomy over surveillance. It should be remembered that this trial began in the pre-PSA era and that the data are not the same as we would see today," said E. David Crawford, MD, professor of surgery, urology and radiation oncology and head of the Section of Urologic Oncology at the University of Colorado Health.

"I believe the new finding here is contained in the last sentence of the abstract and states that a large proportion of the long-term survivors in the watching-waiting group have not required any palliative treatment," said Dr. Crawford, who was not involved in this study.

"We need to do a better job in the United States and worldwide in selecting more men for active surveillance. We have new markers developed in the past couple of years to assist including ConfirmMDX, Prolaris, and OncotypeDX. Let's use these to select more men for active surveillance," he said.

This study was published in the March issue of The New England Journal of Medicine.

Research funding was provided by the Swedish Cancer Society, the National Institutes of Health, the Karolinska Institute, the Prostate Cancer Foundation and the Percy Falk Foundation.

The researchers disclosed no conflicts of interest.

Review Date: 
March 5, 2014