Scandinavian Study Shows Prostatectomy Patients Do Better, Live Longer
When men with curable prostate cancer -disease that has not spread widely beyond the prostate - undergo radical prostatectomy, they are much less likely to have the cancer come back, and much less likely to die of the disease than men who don't have surgery.
This has been illustrated dramatically by a large Scandinavian trial published three years ago, and by a follow-up report, published recently in the New England Journal of Medicine. The results of both publication shave rocked the way prostate cancer is perceived in Sweden, Finland, and Iceland -where the mainstay of treatment traditionally has been watchful waiting and where, sadly, most men with prostate cancer in those countries eventually die of it. In the first report, nearly 700 men were randomly assigned either to radical prostatectomy or to watchful waiting. The results provided the first concrete evidence of something American doctors had known anecdotally for years - that treating localized disease reduces deaths from prostate cancer. During the average follow-up of six years, twice as many men in the watchful waiting group died of prostate cancer - which meant, the scientists concluded, that radical prostatectomy can reduce prostate cancer deaths by about half. That study brought hope that treatment can make a difference, and the elated scientists anticipated that with a longer follow-up, the differences in cancer deaths between these two groups would become even more clear.
They were right. At 10 years after the study began (the results published in the second paper), half of the men in the watch-
|Radical prostatectomy reduced the likelihood of dying from prostate cancer by 40 percent.|
ful waiting group had died from prostate cancer. Radical prostatectomy reduced the likelihood of dying from prostate cancer by 40 percent. And the overall survival (including all causes) was significantly better in the men who underwent radical prostatectomy. Surgery was of greatest benefit to men who were younger than age 65 at the time their cancer was diagnosed. In that age group, after 10 years, 19 percent of the watchful waiting patients had died of prostate cancer, but fewer than 9 percent of the men who underwent surgery had died. Also, surgery reduced the risk of local recurrence of cancer by 67 percent, and of the cancer's spread to distant sites by 40 percent. "The impact on distant metastasisis all the more impressive here," notes Patrick C. Walsh, M.D., University Distinguished Service Professor of Urology,"because hormonal therapy was given more often to the men in the watchful waiting group than to the men who underwent radical prostatectomy." The study's authors concluded: "We expect the benefits of this surgery will increase during longer periods of follow-up."
One important note about this study: Most - 75 percent - of the Scandinavianmen were diagnosed with cancer advanced enough to be felt during a physical exam, with an average PSA of 13 ng/ml. This is in sharp contrast to the United States today, where 75 percent of men are diagnosed, on average, five years earlier, and at a much more curable stage – with non-palpable cancer, detected because of a change in PSA. However, says Walsh, "Although these men had more advanced disease than we commonly see today in the United States, they are very similar to the men who underwent surgery in the early 1990s, before the wide-spread use of PSA screening."
In 1992, 104,000 men underwent a radical prostatectomy in the United States, Walsh continues. "If we apply the outcome from the recent Scandinavian trial to these figures, we would expect that there would be at least 5,000 fewer men dying of prostate cancer 10 years later, which is close to what we have experienced." In applying the findings of the Scandinavian study to today's patients, who are diagnosed with smaller cancers, detected much earlier, the authors note that it may take much longer to see the difference in survival and quality of life, "but the removal of small tumors may facilitate surgery and result in fewer side effects."
Just before the New England Journal Of Medicine study was published, an investigation by researchers at the University of Connecticut and McGill University in Canada appeared inthe Journal of the American Medical Association.The article made headlines with its authors'conclusion that their findings do "not support aggressive treatment for localized low-grade prostate cancer." However, the JAMAstudy's patient population was limited in several ways: First, 60 percent of the patients were diagnosed with low-grade tumors found during transurethral resection of the prostate, a treatment for benign prostate enlargement. "Today these low-grade (Gleason 2-4) tumors are rare," notes Walsh, "because with the availability of medical therapy, fewer men are undergoing surgery for an enlarged prostate. I haven't operated on a patient with Gleason 2-4 disease in the last 10 years. What the authors' data supported, and what they should have stated in their conclusion, was that men with Gleason scores greater than 4 - the vast majority of all men diagnosed today - have a significant risk of dying from prostate cancer, and may benefit from treatment." Also, this paper did not accurately describe the natural history of untreated prostate cancer, because 42 percent of the patients received hormonal therapy within six months of diagnosis. And finally, because many of the study's patients also had serious, chronic health problems - when the paper was written, only 6 percent of the patients in the study were still alive, and most had died from other causes - the results aren't helpful to an otherwise healthy man trying to decide on the best course of treatment for cancer.