Aggressive treatment of early prostate cancer, and not watchful waiting,
improves the survival of older men, a new study
suggests.
“There has been a
belief that watchful waiting was the safest treatment for older men with
moderate prostate cancer,” said Dr. Yu-Ning Wong, an oncologist at Fox Chase
Cancer Center who is lead author of the report in the Dec. 13 issue of the
Journal of the American Medical Association. “Our study suggests there
may be a survival benefit,” Wong said.
But a more
definitive answer will have to wait for the outcome of controlled studies that
are under way, Wong added.
“Our study was
observational,” she said. “We looked at the records of men treated or not
treated for prostate cancer. It was not a randomized, controlled
trial.”
The issue of
treatment vs. watchful waiting has grown in importance as more men live longer;
many are diagnosed with low- and intermediate-grade cancer that poses no
immediate threat to their lives.
The study looked at
data on more than 44,000 such men, aged 65 to 80, who survived a year or more
past diagnosis. About three quarters of them — 32,000 — had surgery or
radiation therapy in the six months following diagnosis. Another 12,600 did not,
as the physicians opted for watchful waiting.
The death rate for
men who received treatment was 31 percent lower over a 12-year follow-up period,
the researchers reported. The death rate was 23.8 percent for those who had
treatment, compared to 37 percent for those who did not.
The reduced death
rate was seen in all subgroups, including men aged 75 to 80 at diagnosis and
those with low-risk disease.
“The cautionary note
when interpreting this trial is that although it suggests that every man should
be treated radically, the decision must be made case by case,” said Dr. Mark S.
Litwin, a professor of urology and public health at the University of
California, Los Angeles, and co-author of an accompanying
editorial.
As a general
principle, “we know that most men don’t die from it [prostate cancer], but die
with it,” Litwin said. “One has to be careful to be sure not to over-treat. The
treatment can be worse than the disease.”
When making a
decision, the doctor “has to be very astute in assessing a patient’s general
functional status and overall health,” Litwin said. And the patient’s voice must
be heard, he added.
“The patient should
be the driving voice,” Litwin said. “The physician must be cautious not to be
paternalistic because this generally is not an acute, life-threatening
illness.”
Some smaller studies
have indicated a benefit for watchful waiting, but most have found better
survival with treatment, Wong said.
“Ultimately, a
randomized, controlled trial will give us the answer we are looking for,” Litwin
said.
Such a trial is
being done by the U.S. Veterans Administration, Wong said. Results are expected
in a few years.
Until then, “the decision needs to be based on the patient’s overall
condition and personal beliefs,” she said.
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