By Mark A. Kelley, MD |09/20/16
Last week, the New England Journal of Medicine published an important study about prostate cancer. The research showed that men with early stage prostate cancer can safely choose “monitoring” instead of treatment.
This might seem like a strange recommendation for such a serious disease. However, prostate cancer is an unusual malignancy. It is more common as men age but it rarely causes death.
Prostate cancer can be detected very early with the simple blood test, the prostate-specific antigen (PSA). The treatment is either surgically removing the prostate gland or treating the prostate area with external radiation. Both treatments are effective but can cause impotence and incontinence.
This is an unusual paradox in cancer treatment. A very simple blood test can detect prostate cancer in its early stages but the cancer grows slowly and is rarely fatal. Furthermore, the treatments have important side effects. Should a patient undergo treatment for a cancer that is rarely causes death?
The new study helps to answer that question. The major goal was to determine if prostate-cancer survival is better with early treatment versus to a “watch and wait” strategy. The study recruited over 1600 men between 50-70 years old with localized, early stage prostate cancer. These volunteers were randomly assigned equally to one of three groups: immediate surgery; immediate radiation; or “active monitoring” of their cancer by a medical specialist. During that monitoring, patients whose cancer became more aggressive were offered treatment. All patients, on average, were followed for ten years.
The major results of this study are:
1. For all patients with localized prostate cancer, the 10-year survival from the disease was 99%.
2. There was no survival advantage from early treatment or the type of treatment (surgery vs. radiation).
3. Progression of prostate cancer occurred in 20% of the “active monitoring group” and in less than 10% in the treatment groups. This difference did not have any affect on survival over the ten years of the study.
4. About 60% of the “active monitoring group” eventually had surgery or radiation during the follow-up period. However, the remaining 40% had no progression of their disease.
What did we learn from this study?
The study confirms that localized prostate cancer does not behave aggressively. Over ten years, survival is excellent. Nearly half of the patents assigned to follow-up had no progression of their disease. They were spared unnecessary procedures. This lends support to follow-up as an option for patients.
What still remains in question?
More of the “active monitoring” patients had progression of their cancer compared to early treatment patients. (20 % vs. 10 %). This difference did not affect mortality in this study. However, the significance of this finding is unknown and warrants further research.
What will physicians recommend now?
Before this study was published, most experts have been offering follow-up as an option for men with localized prostate cancer. This new study gives convincing evidence that follow-up, instead of immediate treatment, can be a safe choice for newly diagnosed prostate cancer patients. In 40% of such patients, the tumor remains stable over a decade and requires no treatment. If the tumor grows during that period, and treatment is needed, the survival rate is still 99%.
A warning: in this study, specialists carefully followed men with “active monitoring”. Men who do not have this follow-up may have less favorable results.
This study may be especially helpful for patients who are hesitant about treatment. Those concerns are often about the complications of treatment or the risks of co-existing medical conditions. For such men, this study confirms that monitoring is a reasonable choice. This information will make it easier for doctor and patient to plan the next steps.
This is a great example of how medical research can help patients make informed choices.
To read more about prostate cancer, see the American Cancer Society website.