A new study in the New England Journal of Medicine finds that mortality rates are lower for younger men having surgery for prostate cancer, compared with those who follow watchful waiting.
Prostate cancer is common among older men and rare in men under the age of 40. For most forms of cancer, treatment at as early a stage as possible is preferred, but prostate cancer is less straightforward. A prostate tumor may grow very slowly without any symptoms, or it may grow very quickly and spread to other parts of the body.
Each year, more than 230,000 men in the US are diagnosed with prostate cancer, and the best course of treatment for them is a much-debated topic.
For instance, in 2013, Medical News Today reported that prostate cancer researchers were arguing for more watchful waiting to manage the disease, rather than moving straight to aggressive treatment or surgery.
The researchers behind that study claimed that: "Radical prostatectomy or radiation therapy, the usual treatments for prostate cancer, can have negative side-effects such as impotence and incontinence [...] Choosing active surveillance could prevent this decline in quality of life."
But the 2013 study contradicted the findings of another New England Journal of Medicine-published study from 2011, which suggested that men under 65 have much better outcomes with radical prostatectomy than watchful waiting. That study found that mortality was 40% lower among younger patients who had their prostate surgically removed.
Lower mortality rates in men who have surgery, compared with watchful waiting
The new study used data from the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4). This trial randomized 695 men who had early prostate cancer to either treatment with surgery or watchful waiting with no initial treatment. The progress of the men was monitored for up to 24 years.
Over the course of the study, 200 of 347 men in the surgery group and 247 of the 348 men in the watchful waiting group died. In the surgery group, 63 of these deaths were due to prostate cancer, and in the watchful waiting group, 99 of the deaths were due to prostate cancer.
"The latest results from the SPCG-4 trial indicate that surgery can not only improve survival, especially in men diagnosed at a younger age or with intermediate-risk disease, but also that surgery can reduce the burden of disease in terms of development of metastases and the need for palliative treatment," says co-author Jennifer Rider.
Researchers warn against over-treatment
But the researchers do urge caution when interpreting their results.
"Our study shows that surgery reduces the risk of dying from prostate cancer by 44%. So surgery does pay off. But as we look closer at different groups, what emerges is that this does not apply to all patients," says Prof. Jan-Erik Johansson, research leader of the study.
The researchers believe over-treatment is an important issue and point to an American study showing that modern screening tests pick up patients with a low risk of developing cancer that is life-threatening. As a consequence, many men undergo unnecessary surgery, which comes with associated side effects. A third of men who have surgery for prostate cancer become incontinent and 80% become impotent.
"Therefore the patient himself must assess the risks with the operation as well as what he may gain from undergoing surgery based on his age, other diseases as well as his desires in life," says Prof. Johansson, who adds:
"In the future, we hope to secure further knowledge of what markers doctors can use to more accurately predict the prognosis for patients, helping them to make more informed choices about their treatment. Good markers would help doctors to save more lives without causing unnecessary pain."
Written by David McNamee