Men under 65 with early stage prostate cancer have much better outcomes with radical prostatectomy than watchful waiting, Swedish researchers report in the New England Journal of Medicine. They found that all-cause mortality was 40% lower among the younger patients who had their prostate surgically removed.

The risk of prostate cancer death among the men under 65 with low risk disease who underwent a radical prostatectomy was 50% lower at 15 years.

Anna Bill-Axelson, MD, PhD, of University Hospital in Uppsala, Sweden, and team from the Karolinska Institute, Sweden, added that there was no significant benefit for radical prostatectomy over watchful waiting for men aged at least 65 years.

The authors wrote:

“The benefit is obvious among men younger than 65 years of age, but it is still unclear whether the benefit extends to older men.”

The benefits were also there for younger men whose tumors were deemed to be low-risk after being examined under a microscope.

In approximately 95% of the cases in this study, Swedish men, they were treated because they had symptoms. In the USA most cases are identified after a PSA blood test – mainly before symptoms emerge. This makes one wonder whether the benefits depend on how the patient was diagnosed.

Experts say the majority of prostate cancers diagnosed in the USA will not become life-threatening. However, as there is no fool-proof way of determining which ones will become dangerous, a considerable proportion of men who don’t need treatment are treated.

This study was funded by the Swedish Cancer Society and the US NIH (National Institutes of Health).

In 1989, just under 700 males less than 75 years of age were either operated on immediately or monitored and treated if their cancer worsened. The majority of them had symptoms, such as blood in urine, urinary difficulties, blood in semen, erectile problems, lower back pain, as well as pain and/or discomfort in their upper thighs and hips.

They were followed up for 13 years. 166 of those who had undergone surgery died, compared to 201 who had been monitored. Among those who had undergone a radical prostatectomy, 55 died from prostate cancer, compared to 81 in the watchful waiting group.

The researchers wrote that those who underwent surgery had a 38% lower risk of dying from prostate cancer. However, the authors stress that the benefits were only clearly there for those aged less than 65 years.

A larger percentage of the younger men who underwent watchful waiting eventually had cancer that spread to other parts of the body, and more of them subsequently needed hormone treatments.

58% of those who underwent surgery had some sexual problems, while 32% had urinary problems.

As surgery techniques have improved, which include nerve-sparing approaches, there are fewer side effects today.

The authors concluded:

” Radical prostatectomy was associated with a reduction in the rate of death from prostate cancer. Men with extracapsular tumor growth may benefit from adjuvant local or systemic treatment.”

218,000 men are diagnosed in the USA each year with prostate cancer. Approximately half of them opt for immediate surgery, radiation or hormones. In Europe, on the other hand, the majority chose watchful waiting and only operate if the cancer worsens.

Prostate cancer rates vary considerably around the world. It is most common in the USA, then Europe and least common in South and East Asia. In the USA, prostate cancer rates are highest among African-Americans and lowest among men of Asian descent – Caucasian men are in between. However, prostate cancer rates are 15 times higher among Chinese-American men compared to males who live in China. Some of this difference may be due to higher detection rates in the USA.

Prostate cancer is rare in males under the age of 50. Prostate cancer is the second leading cause of death in America and the United Kingdom, after lung cancer.

Over four-fifths of males will develop prostate cancer by the time they are 80 years old. As it is typically slow-growing and therefore relatively harmless, most elderly males will opt for watchful waiting.

“Radical Prostatectomy versus Watchful Waiting in Early Prostate Cancer”
Anna Bill-Axelson, M.D., Ph.D., Lars Holmberg, M.D., Ph.D., Mirja Ruutu, M.D., Ph.D., Hans Garmo, Ph.D., Jennifer R. Stark, Sc.D., Christer Busch, M.D., Ph.D., Stig Nordling, M.D., Ph.D., Michael Häggman, M.D., Ph.D., Swen-Olof Andersson, M.D., Ph.D., Stefan Bratell, M.D., Ph.D., Anders Spångberg, M.D., Ph.D., Juni Palmgren, Ph.D., Gunnar Steineck, M.D., Ph.D., Hans-Olov Adami, M.D., Ph.D., and Jan-Erik Johansson, M.D., Ph.D. for the SPCG-4 Investigators
N Engl J Med 2011; 364:1708-1717May 5, 2011

Written by Christian Nordqvist