`Wait-and-watch' on prostate cancer may not be best idea for older men

December 15, 2006|By Josh Goldstein | Josh Goldstein,McClatchy-Tribune

For years, doctors have urged older men with early-stage, low-risk prostate cancer to "watch and wait" -- skip treatment until tests showed the cancer was growing aggressively.

Now, a study suggests there's a significant benefit from treating men older than 65 surgically or with radiation therapy.

"We found that men who had either a radical prostatectomy or radiation therapy within six months of their prostate cancer diagnosis were 30 percent less likely to die than those who did not undergo treatment," said Yu-Ning Wong, a medical oncologist at Fox Chase Cancer Center in Philadelphia and lead author of the study.

The investigation, by doctors from Fox Chase and the University of Pennsylvania, was published this week in the Journal of the American Medical Association.

Using several national cancer databases, Wong and her colleagues examined the overall survival of 44,630 men with low- and intermediate-stage prostate cancer. The patients ages 65 to 80 were diagnosed with the disease between 1991 and 1999.

The doctors reported that over a 12-year period, 37 percent of the men with prostate cancer who took the watchful waiting approach died, compared with 24 percent of those who chose active treatment.

While acknowledging that the study relied on "observational data," Wong said it "should influence the discussion that patients have with their doctors."

Wong said she undertook the project because of a lack of strong medical evidence on the best course of treatment.

"In previous years, it was thought that watchful waiting was the safest approach in older men given the uncertainty of the benefits of treatment and the slow growth of some prostate cancers," she said.

Richard Kaplan, 65, of Lawrenceville, Pa., weighed the benefits of treatment versus side effects very carefully after being diagnosed with prostate cancer in June.

"Once this happens, you are sort of plunged into it," Kaplan said.

Radiation therapy, he discovered, required visiting a hospital five days a week for two months. Surgical removal of his prostate didn't appeal either, given a high risk of impotence.

Kaplan's PSA -- prostate specific antigen, a key indicator of cancer -- fell from 4.1 to 3.3. He decided to wait and do nothing.

In Philadelphia, Joe Carfagno, 70, made a different choice. He was also diagnosed in the summer. "I didn't want to wait and see if it would grow or if it would move to some other area," he said. With his wife's blessing, Carfagno had surgery.

In the study, the risk of dying from prostate cancer was low for both groups. Only 314 of the watchful waiting group, or 2.5 percent, died of prostate cancer, while only 612, or 1.9 percent, of the treatment group died of the disease.

"That translates into needing to treat 200 men over a 12-year period to save one person," said H. Ballentine Carter, a professor of urology and oncology at the Johns Hopkins School of Medicine. "The explanation, in my mind, is that competing causes of death far exceed the chances of dying from prostate cancer."

Last year a small Scandinavian study published in the New England Journal of Medicine found a benefit for surgically removing prostates compared with watchful waiting for low-risk patients. Most of the benefit in that study was for men younger than 65.

"The bottom line of these studies is that ... there is no one right way to treat prostate cancer," said Leonard Gomella, chairman of the department of urology at the Kimmel Cancer Center at Thomas Jefferson University in Philadelphia.

Gomella, a surgeon who cares for many men with the disease, said that a decision to actively treat versus waiting to see whether the cancer progresses is individual for patients and their families.

"If we had a treatment for this disease with no side effects, this would not be an issue," Gomella said.

Advances in surgical and radiation therapy techniques have reduced the incidence of those negative outcomes. But many men treated for the disease still experience urinary incontinence, rectal bleeding and erectile dysfunction.

Steven J. DiBiase, chief of radiation oncology at Cooper University Hospital in Camden, N.J., said half the men who underwent radiation would have problems with impotence and those getting surgery faced even higher risks.

Older men with slow-growing tumors are often warned that it won't be cancer that kills them and the risks of side effects are not worth treatment. This study may weaken that argument.

"It is very important for patients to take a few months and gather information and make a well-informed decision," DiBiase said.

More than 230,000 men in the United States were diagnosed with the disease last year, and 30,000 died from it, according to an American Cancer Society estimate.

Gomella noted that virtually every man, if he lives long enough, will get prostate cancer.

So the debate over the best approach for managing the disease will continue and several randomized studies comparing active treatment to observation are now under way.

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