The study, published in The New England Journal of Medicine, was the first to include detailed information from patients about the side effects of treatment.
A new study offers important information to men who are facing difficult decisions about how to treat early prostate cancer — or whether to treat it at all. Researchers followed patients for 10 years and found no difference in death rates between men who were picked at random to have surgery or radiation, or to have “active monitoring” of the cancer, with treatment only if it progressed.
Death rates from the cancer were low: about 1 percent of patients at 10 years.
But the disease was more likely to progress and spread in the men who opted for monitoring rather than for early treatment, and by the end of 10 years, about half the patients in the study who had started out being monitored wound up having surgery or radiation.
The patients are still being followed, which should reveal whether the progression eventually leads to higher death rates in the group that was assigned to monitoring.
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Active monitoring involves regular clinic visits with physical exams of the prostate, periodic biopsies and blood tests for prostate-specific antigen, or PSA, a substance that may indicate the disease is worsening.
The study, published Wednesday in The New England Journal of Medicine, was the first to include detailed information from patients about the side effects of treatment. Men who had surgery to remove the prostate were the most likely to have lingering problems with impotence and incontinence. Those given radiation did not have incontinence but did have bowel problems at six months, usually with gradual improvement. Sexual function also diminished after radiation but recovered somewhat.
Doctors say the findings should help reassure men who choose treatment that, based on the 10-year survival figures, surgery and radiation are equally reasonable choices for early prostate cancer. “I can counsel patients better now,” Dr. Freddie Hamdy, a leader of the study from the University of Oxford, in England, said in an interview.
Dr. Peter Scardino, a prostate surgeon and chairman of the department of surgery at Memorial Sloan Kettering Cancer Center in New York who was not involved in the study, said the research was important because there was little previous data comparing surgery, radiation and careful monitoring in men with early prostate cancer.
Scardino said the findings helped confirm that active monitoring is a valuable approach for many men. He said it was appropriate for a third to a half of men with early prostate cancers, and that only a third of those patients would need treatment within 10 years.
But Scardino emphasized that the monitoring must be done regularly and with great care, for the rest of a patient’s life. He added that an important message from the study is that early prostate cancer is not an emergency, and men have time to decide what to do about it.
In 2012, the U.S. Preventive Services Task Force, an independent panel of experts, recommended against routine screening for prostate cancer with the PSA test. The group said screening finds many tumors that may never have harmed the patient, and leads too many men into unneeded surgery or radiation, with their troubling side effects.
Hamdy’s team set out to address the quandary. They studied 1,643 patients in Britain ages 50-69 who had early prostate cancers, found with routine PSA testing and then a biopsy if the PSA was abnormal. All the cancers were localized, meaning they were confined to the prostate and had not spread.
The patients were then assigned at random to one of three groups: A third had surgery, a third had radiation, and a third had active monitoring.
Though death rates from the cancer did not differ, more men on active monitoring had progression. The disease spread to distant parts of the body in 33 men on monitoring, 13 who had surgery and 16 who had radiation. The differences were statistically significant.
Other progression, to nearby tissue outside the prostate, was also more common with monitoring: 112 cases, compared with 46 each in the surgery and radiation groups.
As time went on, more and more of the monitored patients wound up having treatment.
Douglas Collett, a retired construction worker from Cromhall, said he was horrified when he was diagnosed with prostate cancer. “It hit me like a sledgehammer,” he said. “My initial reaction was to get rid of it.”
But after reading up on the risks and benefits of surgery and radiation, Collett, 73, said he was relieved to have been assigned to the active monitoring group, and believes men should be fully informed about the various strategies.
He realizes the disease could progress and if it does he will probably have radiation. In the meantime, he said, “I’m fit as a flea.”