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.

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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