US: 20-year study shows surgery for early prostate cancer may not save lives

A study that began in 1994 has provided further evidence that prostate cancer surgery offers negligible benefits to many men with early-stage disease

In such men, who account for most cases of newly diagnosed prostate cancer, surgery did not prolong life and often caused serious complications such as infection, urinary incontinence and erectile dysfunction.

The study compared surgery with observation in men with early-stage prostate cancer. With the latter, men only were treated if they developed bothersome symptoms, such as urinary difficulty or bone pain. Such symptoms may indicate progression of the cancer. Many men in the observation group received no treatment at all because early-stage prostate cancer often grows slowly and rarely causes symptoms.

“About 70 percent of patients newly diagnosed with prostate cancer cases are in the early stages, meaning the cancer is confined to the prostate gland, and they have nonaggressive tumours. As such, these patients have an excellent prognosis without surgery. This study confirms that aggressive treatment usually is not necessary,” said co-author Gerald Andriole, director of Washington University's Division of Urologic Surgery.

The study, the Prostate Cancer Intervention Versus Observation Trial, (PIVOT), is one of the largest and longest involving cancer patients. When it began in 1994 the prostate-specific antigen blood test for prostate cancer had just became routine. With many more men diagnosed with prostate cancer, the standard treatment for all prostate cancers became surgery or radiation, with the thinking that removing or irradiating the tumour would increase survival.

But over the next decade, reports of treatment-related complications raised concerns, as did data indicating that most early-stage cancers grew so slowly they were unlikely to cause health problems.

The researchers randomly assigned 731 men with localised prostate cancer to receive either surgery or observation at one of 52 centers. Of the men who had prostate cancer surgery, 223 (61 per cent) died of other causes after up to 20 years of follow-up, compared with 245 men (66 per cent) in the observation group, a difference that is not statistically different. Further, 27 (7 per cent) of men in the surgery group died of prostate cancer, compared with 42 men (11 per cent) in the observation group, but that difference also is not statistically significant.

Technology has advanced since the study began, allowing physicians to more accurately classify tumours and avoid over-treating patients who have prostate cancer.

Of the 364 men treated with surgery, 53 (15 per cent) suffered from erectile dysfunction, and 63 (17 per cent) reported having incontinence. Another 45 developed other complications.

Senior author Timothy Wilt, a physician-researcher with the Center for Chronic Disease Outcomes Research at the Minneapolis VA Health Care System and a professor of medicine at the University of Minnesota said, “Our results demonstrate that for the majority of men with localised prostate cancer, selecting observation for their treatment choice can help them live a similar length of life, avoid death from prostate cancer and prevent harms from surgical treatment. Physicians can use information from our study to confidently recommend observation as the preferred treatment option for men with early prostate cancer.” 



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