(CNN) -- When it comes to
prostate cancer, aggressive surgery saves lives and leads to a better quality
of life, according to a new study that could inflame the debate over how best
to treat the disease -- and in some cases, whether to treat it at all.
The
paper, published in the New England Journal of Medicine, is an update on a
study that was launched in Sweden, Finland and Iceland a quarter-century ago.
Nearly 700 men newly diagnosed with prostate cancer were split into two groups:
half had their prostate gland fully removed -- a radical prostatectomy -- and
half were followed through a protocol of "watchful waiting," where
doctors only treated them if symptoms progressed.
On
average, men who underwent immediate surgery lived longer, were less likely to
see the cancer spread and had fewer complications from the disease. The
longevity benefit was greatest for men in their 50s and early 60s, where over
an 18-year period, surgery cut the death rate by more than a third.
That
result might seem obvious, but watchful waiting is frequently recommended
because of surgery's side effects and because most prostate cancers grow so
slowly that men will die of other causes before the cancer can kill them.
The new
study is likely to give pause to some of those patients.
"Our
research suggests that we overtreat many men," says Dr. Peter Carroll,
chairman of urology at the University of California, San Francisco. "But
at the same time, we may undertreat those with high-risk cancers."
The
authors of the new paper say they aren't looking to overturn current guidelines
that recommend active surveillance -- waiting, with regular testing to see if
the cancer has progressed -- in men with low-risk disease. "The numbers in
each subgroup are low, and the risk categorization is less sophisticated than
current standards," they wrote, urging caution in interpreting the
results.
Dr. Otis
Brawley, medical director of the American Cancer Society, says the paper
generally supports current practice. He notes that patients in the Swedish study
likely had more aggressive disease to start with because they were diagnosed
after complaining of symptoms.
According
to Brawley, just 12 percent of U.S. prostate cancer patients are found because
they show symptoms; the rest are identified through PSA tests and other
screening.
"Those
guys with high-grade tumors, those are the guys we ought to be treating,"
Brawley says. He notes that other studies, including the highly regarded PIVOT
trial, have found even fewer benefits from surgery. "They all say the same
thing, that radical prostatectomy for men 65 and above seems not to save
lives."
But
others are struck by the finding that all groups in the study, even men over
65, suffered fewer side effects when they initially opted for surgery.
"This drills down that it's not all about mortality," says Dr. John
Davis, director of the prostate surgery program at MD Anderson Cancer Center in
Houston.
Davis
explains that many patients who choose a regimen of watchful waiting or its
close cousin, "active surveillance," eventually undergo repeated
biopsies, radiation therapy or other measures.
"I
would argue that the side effects of surgery are much less than those of
long-term hormone therapy," which reduces the level of hormones like
testosterone that promote the growth of prostate cancer.
While
surgery often leads to sexual dysfunction and/or urinary incontinence, hormone
therapy has its own dangers, including low sex drive, hot flashes, loss of
energy, weight gain and an increased risk of heart disease.
Carroll
agrees that mortality is only part of the picture and says the new study
underscores a need to better differentiate between high- and low-risk cancers.
"Although
it is often said that there is little benefit (from surgery) to those over 65,
this appears not to be the case. It's more a function of the aggressiveness of
the tumor and the health of the patient."
News Source: edition.cnn.com
0 comments:
Post a Comment