Should I get surgery to remove my prostate cancer, or wait and see if it develops into a more dangerous condition? It’s an excruciating question for men which involves mortality and also profound issues about lifestyle and sex life. Now there is new research which finds that men who opt for surgery live up to three years longer.
The non-surgical approach to early stage prostate cancer is known as watchful waiting, and is based on the fact that prostate cancer is often slow growing, which allows some men to not have treatment unless symptoms develop or the disease gets worse.
Read MoreOf the nearly 700 men randomly assigned to surgery or watchful waiting the advantage for surgery appeared striking.
- 71 deaths in surgery group
- 110 death in the watchful waiting group
Leading experts in prostate cancer said the study was significant. The study provides “unique insights into the benefits of radical prostatectomy” according to Dr. Herbert Lepor, Chairman of Urology at NYU Langone Health.
“The study should allay any concerns that treatment in men who need it is beneficial”, said Dr. Eric Klein Chairman of the Glickman Urological & Kidney Institute, at the Cleveland Clinic
As with any medical research it's important to look at exactly what kind of patients were in the study before knowing how results may apply to an individual patient.
The study was done in:
- Men whose prostate cancer has not spread
- Had a life expectancy greater than 10 years
- Were younger than 75 years old
- Had no other cancers likely to shorten their survival
The mean age of the men in the study was 65 years old. The trial was done in 14 centers in Sweden and Finland and Iceland starting in 1989 with follow-up through 2017. Eighty per cent of the men in the study had died by that time with one third of those deaths from prostate cancer.
The study found that not only did surgery compared to watchful waiting extend survival by three years, but the surgery group also had lower mortality due to prostate cancer and lower risk of metastasis. Dr. Lepor believes “for men with a ten year life expectancy where sexual dysfunction is a low or non-existent priority, the present study suggests that the risk: benefit of surgery is quite favorable.” And he points to another important finding in the study. The long follow-up provided insights into what happens when patients with prostate cancer receive no treatment and are then followed for many years with nothing but watchful waiting. “Over half the men who chose watchful waiting did not develop metastasis which highlights the high rate of unnecessary curative treatment,” Dr. Lepor believes.
There are widely varying statistics on the percentage of men who will experience problems with controlling their urine and getting and keeping an erection sufficient for penetration. An article by Dr. Lepor which reviewed the major studies on side effects concluded that men undergoing surgery will experience "significant short term urinary incontinence, lower urinary tract symptoms, and sexual dysfunction" that may impair their quality-of-life. But the article also noted that these are problems faced by men in the general population as they get older.
The urinary incontinence and sexual dysfunction can also be linked. One article which reviewed other studies found that incontinence can present “at the time of orgasm…or arise during arousal.” The article also noted orgasmic disturbances including “altered perception of orgasm, anorgasmia (orgasm cannot be achieved), and orgasm-associated pain.” And there have been reports of penis shortening following the operation. Dr. Stephen Freedland, of Cedars-Sinai Medical Center, discussed this problem with SurvivorNet.
While the new Scandinavian study provides important information about the benefits and risks of prostate cancer surgery, the study has some important limitations. The authors acknowledge an important one: treatment of prostate cancer in the 1990s was far different than it is today. And these differences could influence the applicability of these results to today’s patients. “As a result of widespread PSA testing today most men have non-palpable (can’t be detected by physical exam) tumors, whereas in our trial the majority of men have clinically detected palpable tumors.” What’s more men today have much more sophisticated testing and as a result, the authors said in their trial the ability to detect cancer was much lower.
But Dr. Klein believes the findings of the study are not outdated. He says, “the results are very relevant to men diagnosed today, where new tools including improved pathological classification, MRI biopsy guidance, and gene expression profiling allows us to more accurately distinguish between tumors needing treatment and those that can be safely watched.”
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