Localized prostate cancer treatment: Is surgery no longer an option?

Localized prostate cancer treatment: Is surgery no longer an option?Prostate cancer is in the news again, thanks to a recent study in the New England Journal of Medicine.

The study looked at surgery versus observation for localized prostate cancer.  According to MedPage Today, “Neither overall mortality nor cancer-specific mortality differed significantly between men who had surgery and those who were prospectively followed. The absolute difference was less than 3% for both outcomes.”

So, what now?

Reading media reports, there are no shortage of doctors willing to comment to frame its conclusions.  As with PSA screening, most primary care doctors see the findings as an indictment of surgery, while urologists take a more measured view:

William Catalona, MD, a urologic surgeon at Northwestern University in Chicago, said the results cannot be extrapolated to the general population because VA patients differ from those seen outside the VA system, including older age and more coexisting health problems. He also noted that the trial showed that surgery substantially reduced suffering.

“The goal of radical prostatectomy is to prevent suffering and death from prostate cancer,” Catalona said by email. “In this regard, careful inspection of the data reveals that the occurrence of metastases was 60% lower and the prostate cancer mortality rate was 37% lower in men treated with surgery (40% lower at 12 years). In fact, most of the outcomes in their forest plots favor surgery over observation.”

The path of prostate cancer surgery isn’t clear cut, and more than ever, needs to be discussed with each individual patient.

Both primary care doctors and urologists should use this study in their discussions with their prostate cancer patients.  Explain that surgery for localized prostate cancer isn’t necessarily associated with a mortality benefit, and can cause an increased incidence of side effects like impotence and urinary incontinence.

It would be wrong to frame the findings as a dismissal of surgery.  For some men, if they understand the risks and benefits, surgery is the right choice.

I agree with Ruth Etzioni, a biostatistics researcher at the Fred Hutchinson Cancer Center in Seattle, when she says,

If this study is reported in the press the way it has been reported in the journal – as indicating that radical prostatectomy is not beneficial when compared with watchful waiting – then this will represent a further unsound nail in the coffin of important efforts to manage this most common of male malignancies,” Etzioni said in a written response.

When one takes the PIVOT study results as reported, together with the [US Preventive Services Task Force] recommendations regarding PSA screening, one could then easily conclude that we should not be screening for or treating prostate cancer. This would be a mistake.

Indeed.  In our quest for simple answers, emerging studies are showing us that the screening and treatment of prostate cancer is anything but.

Localized prostate cancer treatment: Is surgery no longer an option?Kevin Pho is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.facebook.com/people/Roy-M-Poses/757544028 Roy M Poses

    I am a little surprised that you view “the path of prostate cancer surgery” as not “clear
    cut.” The PIVOT study clearly shows that radical prostatectomy for early stage prostate
    cancer benefits few people, but harms many.

    To review, the trial did not show a significant decrease in total or prostate-cancer
    specific mortality due to surgery. It did show a numerically small decrease in bone
    metastases (at 15 years), 10.6% in observation patients, 4.7% in surgical patients, for an
    absolute decrease of 5.9%

    On the other hand, it showed that surgery produced a lot of peri-operative complications:
    21.4%. These included some serious problems, e.g., pneumonia, wound infection, sepsis,
    myocardial infaction, etc. The PIVOT trial also showed that the rate of patients with
    urinary incontinence long-term was higher after surgery, 17.1%, than after observation,
    6.3%, an absolute increase of 10.8%. Furthermore, the rate of patients with erectile
    dysfunction long-term was 81.1% after surgery, 44.1 after observation, for an absolute
    increase of 37%.

    Why Dr Catalona thought that the evidence showed that surgery reduced overall suffering is
    beyond me. Perhaps it is very difficult for someone who has spent a career performing such
    surgery to deal with data that in retrospect throws doubt on the wisdom of such practice.

    The results of PIVOT are fairly similar to those of the earlier Scandinavian study (see
    Moyer VA et al. Screening for prostate cancer: U.S. Preventitive Services Task Force
    recommendation statement. Ann Int Med 2012; 157: ). That study showed an absolute decrease in the rate of distant metastases of 11.7% at 15 years, and an absolute decrease in prostate cancer specific mortality of 6.1% due to surgery, but no improvement in total mortality due to surgery. Furthermore, previous trials have shown high rates of peri-operative
    complications, and long-term urinary incontinence and erectile dysfunction.

    In summary, no trial has shown that radical prostatectomy improves overall long-term
    survival. While it may slightly decrease the chance of distant metastases, it greatly
    increases the chances of various bad peri-operative complications, and long-term
    incontinence and ED. So radical prostatectomy seems to produce a fair amount more harm than good. Why would any patient want such surgery?

    There may, however, be a patient sub-group for whom surgery does provide benefits that outweigh its harms. Post-hoc sub-group analyses of PIVOT showed that for men with PSA > 10, surgery did lead to an increase in survival, 13.2% at 15 years. However, these results could be due to chance alone, since multiple other sub-group analyses were performed at the same time.

    So while many may have wished that radical prostatectomy would be a miracle cure, the data
    did not turn out that way. It does seem we need new approaches to prostate cancer. The
    good news, though, is that the PIVOT study confirmed previous data that the prognosis of
    early stage prostate cancer is actually much better than that of nearly all other cancers.
    Only 8.4% of men in the observation group died of their cancer over 15 years.

    • http://www.facebook.com/stanislav.racansky.5 Stanislav Racansky

      I have a question. How two opposite opinions could have come out reading the same statistics?

    • James Sinclair

      I want to thank you for such an eloquent statement. I struggle with this. As a medical oncologist I see the logic in avoiding costly and risky surgery and radiation. As a male entering the risk period for prostate cancer I am not sure what I will do about therapy if I get prostate cancer. A proton center is opening up a few miles from my office. This will drive demand for treatment of early prostate cancer at a cost of $50,000/case. We have more robots than I can count so robot prostatectomy is the only surgery performed. I fear the medical-industrial complex as it pertains to early stage prostate cancer will find a way to convince the public to ignore this important data.

  • http://www.facebook.com/people/John-Wickenden/729562456 John Wickenden

    As to your wonder at the urologist’s odd conclusions it may indeed be a case of making his world cognitively consonant it’s a remarkably strong habit pattern.

  • http://www.facebook.com/people/Arnold-Wax/100000381145770 Arnold Wax

    As a medical oncologist, the key issue here is overall survival. When one has a morbid procedure, versus a less morbid procedure, versus a non-morbid procedure with the same outcomes, it is only logical to practice the first law of medicine, primum non nocere. Why argue, when the facts speak for themselves. I also suggest reviewing the Annals of Internal Medicine article fom volume 155 issue 3 pages 171-178 August 2, 2011 and volume 156 issue 8 pages 582-590 April 17, 2012 for some other insights into this dilemma/controversy.

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