Posted by Bill Sandweg on 13 December 2018.

The New England Journal of Medicine just published the results of a 30 year study from Scandinavia of the effect of radical prostate surgery on the risk of death from prostate cancer.  The study sample was 695 men, all of whom had their cancers detected clinically.  This means that the cancer was large enough to be discovered either by the patient or by the physician during examination.  The study participants were enrolled before the advent of widespread PSA testing.

The study participants were divided into two groups.  Members of the first group underwent a radical prostatectomy, a surgery in which the prostate gland is completely removed.  This surgery has a number of unfortunate side effects, including a high risk of incontinence and impotence.  Members of the second group were monitored carefully for changes in their tumors.  This is called “watchful waiting.”  In the event there is a significant change in the tumor, the doctors will begin treatment.

The study concluded that for men with a clinically detected, localized prostate cancer, radical prostatectomy increased the length of life by almost three years.  The results need to be considered carefully, however, as they may not apply to most patients whose prostate cancer is detected today.  In the first place, in order for a prostate cancer to be detected clinically, the tumor must be a large one.  Since most prostate cancers are slow growing, a large tumor is usually one that has been in the body for some time.  With the advent of widespread PSA testing, most men who are discovered to have prostate cancer will have their tumors detected much earlier than the men in the study.  In other words, the men in the study had what we would consider today to be advanced prostate cancer.  Had they been discovered earlier and enrolled in watchful waiting, they may have received treatment earlier than they did in this study.

Secondly, the longer length of life was only enjoyed by those whose tumors had not escaped the local area and whose Gleason scores were low.  The Gleason score is a measure of determining the aggressiveness of prostate cancer.  A high Gleason score indicates an aggressive tumor, which is more likely to be fatal.  The same is true of cancers which had spread outside the local area by the time they were discovered.  Those patients also had a higher risk of death due to the prostate cancer, but not as high as those with elevated Gleason scores.

Because of these limitations inherent in the study, one of the lead authors, Dr. Anna Bill-Axelson, says surgery may be beneficial for those with high grade, aggressive tumors but active surveillance is a good alternative for those who are otherwise healthy and who have small, slow growing tumors.  The older you are when your prostate cancer is discovered, the more likely you are to die with it than from it.

Each of the big three prostate cancer treatments, radical prostatectomy, radiation and brachytherapy have a high risk of leaving the patient incontinent and incapable of having a functional erection.  For this reason, these treatments should not be undertaken lightly.  Many treaters suggest they be used only in younger men and then only if the tumor is aggressive and watchful waiting has failed.  As many articles have suggested, however, it is often difficult to explain to friends and family that you have prostate cancer and are only going to watch it for the time being.  Many men end up getting pushed by family and friends into aggressive treatment, which they later regret.

The general consensus among doctors who treat prostate cancer is that we treat too many men who don’t really need it.  If you are diagnosed with prostate cancer, take the time to consider your options.  Don’t rush into treatment.