Cautionary note about prostates

Hormone treatment for early cancer may do harm, study says

July 09, 2008|By Jonathan Bor | Jonathan Bor,Sun Reporter

A popular hormonal treatment for prostate cancer does nothing to extend the lives of men over 65 with early-stage tumors and may actually be harmful, according to a study published today.

The report, which reviewed the cases of almost 20,000 older men with early disease, further casts into doubt the common public perception that doing something for cancer is always better than doing nothing.

Most older men whose cancers have not spread beyond the prostate gland would do better to forgo treatment and have their condition monitored, according to authors at the Robert Wood Johnson Medical School in New Jersey.

Drugs that suppress the male hormone testosterone - a proven treatment for prostate cancers that have already spread - are not only ineffective in the early stages of the disease, but also contribute to well-known side effects that include cardiovascular disease, diabetes, bone fractures, fatigue and other ills, researchers said.

"Patients need to think about what the potential side effects could be, not that they have cancer and something needs to be done," said Grace Lu-Yao, a cancer epidemiologist at Johnson and lead author of a study appearing in today's Journal of the American Medical Association.

Prostate cancer is the second most frequently diagnosed cancer in men - after skin cancer - and is the second leading cancer killer among men. Only lung cancer kills more.

About 186,000 new cases are diagnosed and about 28,600 deaths attributed to prostate cancer each year, according to the American Cancer Society. But most new cases are diagnosed in the early stages, when treatment decisions can be difficult to make.

The patients

For this study, researchers tapped a database of 19,271 men ages 66 and older with cancer that was still confined to the prostate. The patients were diagnosed between 1992 and 2002 and tracked through 2006.

The 10-year survival rate was about 80 percent, whether or not the patients had received the hormonal treatment - injections that shut off male hormone that promotes tumor growth.

The median age of the men in the study was 77. Among younger men with localized prostate cancer, options include monitoring the cancer until it shows signs of turning aggressive, or surgically removing the prostate immediately. Removing the prostate cures the disease if the cancer has truly not spread.

Surgery is generally not recommended for older men because many would die of other causes before the cancer killed them, if it spread at all.

Hormonal therapy is a proven treatment for men whose cancers have spread to other parts of the body. Though not a cure, experts say, suppression of male hormone can ameliorate symptoms and, in some cases, lengthen survival.

Is more better?

Since the 1990s, however, many urologists have expanded the use of androgen deprivation therapy, as it's known. They have operated on the theory that "if it works for late-stage cancer, it may work for early stage cancer," said Lu-Yao.

Today, she said, about a quarter of older men with localized prostate cancer receive the treatment.

"The bottom line is that it makes no difference in survival, and it may even be worse for people who have very early stage cancer," she said.

Dr. Patrick Walsh, a urologist at the Johns Hopkins School of Medicine, said there's never been any evidence that hormonal treatments help older men with early-stage disease.

"There are many side effects, including weight gain, hot flashes, loss of muscle mass, a decrease in mental acuity," Walsh said.

Recently, he said, he met a man who had lost strength and dexterity in his hands, making it difficult for him to work as a jeweler.

Patients can also become fatigued and depressed, and all will lose sexual function. But the worst side effects are cardiovascular, he said. The treatment can raise blood lipid levels and exacerbate diabetes, both of which can trigger heart attacks.

Windfall for some

"Many urologists thought in a well-meaning way that they would be benefiting patients," he said. But others saw a financial windfall. In the face of aggressive marketing, they discovered they could earn tens of thousands of dollars a year by marking up the price they pay to obtain the hormone-suppressing drugs.

New Medicare rules have forced doctors to use the least costly alternative, said Lu-Yao, resulting in a possible decline in hormonal treatments for this population.

"Overall, I agree with the results of this paper," said Dr. Michael Naslund, a urologist at the University of Maryland Medical Center. "I use hormonal therapy quite a bit in different types of patients but would not use it in an older man with localized treatment who chooses not to be treated otherwise."

Those who benefit

Naslund said there was a small subset of older patients with early cancer whom he would treat hormonally: those whose cancer cells are highly aggressive and on the verge of spreading. Doctors can identify such patients by observing the shape of their tumor cells under a microscope. Well under 5 percent of elderly patients with localized prostate cancer are in this category, he said.

Indeed, the Robert Wood Johnson study found that survival from prostate cancer was slightly higher among such men who were treated hormonally - but overall, survival was about the same. The men died at the same rate, just less often from prostate cancer.

According to Walsh, there's a simple explanation. Studies have shown that the treatment itself kills a significant number of older men. "It's the cardiovascular disease and the worsening of diabetes," Walsh said.

jonathan.bor@baltsun.comf

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