Research: prostate surgery not so helpful

Here's another data point for men worried about prostate cancer: surgery was no better in saving lives than observation over a 10-year period, according to one of the first rigorous studies to compare the two approaches in American men with early-stage disease.

The U.S.-funded study assigned 731 men across the country with early prostate cancer to have the gland surgically removed or be observed without any attempt at curative treatment. Ten years later, 47 percent of men in the surgery group had died, mostly from other diseases, versus 49.9 percent who were just watched, results published in the New England Journal of Medicine found. The difference wasn’t statistically meaningful.

“There is no question in my mind that what we have been doing in the United States for the last 20 years has hurt a lot of men needlessly,” said Otis Brawley, chief medical officer for the American Cancer Society. “We need to be telling men that there is tremendous evidence that a large number of men with prostate cancer could be watched and don’t need to be treated.”

In May, the U.S. Preventive Services Task Force recommended against using the prostate-specific antigen (PSA) blood test to spot the disease, saying the screening leads to overtreatment and unnecessary side effects.

Currently, only 10 percent of American men with prostate cancer who are eligible for observation choose observation, according to a National Institutes of Health report last year.

The vast majority elect surgery or various forms of radiation in an attempt to cure their cancer. Both forms of treatment have side effects, including impotence. “When men hear cancer they want something done,” said Durado Brooks, director of prostate and colorectal cancers for the cancer society. The idea that some prostate cancers aren’t life-threatening is “very difficult for people to accept because they are accustomed to thinking of cancer as this ravaging, always-lethal condition.”

After a median of 10 years, 171 of 364 men assigned surgery had died, while 183 of 367 assigned to observation died. In the surgery group, 5.8 percent of the men died from prostate cancer compared with 8.4 percent of the men in the observation group. Neither difference was statistically significant.

More than 1 in 5 patients in the surgery group had complications within 30 days of the operation. Urinary incontinence and erectile dysfunction were much more common in men who got the surgery, while men who got observation had a higher rate of developing bone metastases.

“The results are consistent with emerging science suggesting that for the vast majority of men observation can be a wise and preferred treatment choice” if they have localized prostate cancer, said Timothy Wilt, a researcher at the Center for Chronic Disease Outcomes Research at the Minneapolis Veterans Affairs Health Care System, and the study’s lead author.

Follow the link to the full article, print it out, and take it to your doctor to discuss.

If you're a man, read this

Healthy men should no longer receive a PSA blood test to screen for prostate cancer because the test does not save lives over all and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many, a key government health panel has decided.

This issue is not new. I have played the PSA game for more than a decade, and I no longer care to play. My number goes up, I'm off to the urologist. Then it goes down. Then it goes up again, and I'm off to the urologist, who now wants to biopsy. Over and over.

The recommendation:

is based on the results of five well-controlled clinical trials and could substantially change the care given to men 50 and older. There are 44 million such men in the United States, and 33 million of them have already had a PSA test — sometimes without their knowledge — during routine physicals.

“Unfortunately, the evidence now shows that this test does not save men’s lives,” said Dr. Virginia Moyer, a professor of pediatrics at Baylor College of Medicine and chairwoman of the task force. “This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.”

Moreover, there is no evidence that a digital rectal exam or ultrasound are effective, either. “There are no reliable signs or symptoms of prostate cancer,” said Dr. Timothy J. Wilt, a member of the task force and a professor of medicine at the University of Minnesota. Frequency and urgency of urinating are poor indicators of disease, since the cause is often benign.

From 1986 through 2005, one million men received surgery, radiation therapy or both who would not have been treated without a P.S.A. test, according to the task force. Among them, at least 5,000 died soon after surgery and 10,000 to 70,000 suffered serious complications. Half had persistent blood in their semen, and 200,000 to 300,000 suffered impotence, incontinence or both. As a result of these complications, the man who developed the test, Dr. Richard J. Ablin, has called its widespread use a “public health disaster.”

Plenty of reputable people are opposed to this new recommendation. What should you do? Talk to your doctor, and ask a lot of questions about everything you hear. Remember, there's a difference between public health statistics and your own body. Read everything you can. Get a second opinion, and a third. Ultimately, the decision is yours.

You can read a lot more about this here.

Some men get a break on the PSA test

The PSA test is designed to do two things: 1) screen men for prostate cancer, and 2) drive men up the wall with anxiety. That's because it's an imprecise test that can lead to biopsies that aren't needed and surgeries that don't prolong life, but do make it miserable.

Now comes some hope for some men. A blood test at the age of 60 can accurately predict the risk that a man will die from prostate cancer within the next 25 years, according to researchers at Memorial Sloan-Kettering Cancer Center, in New York, and Lund University, in Sweden. This could have important implications for determining which men should be screened after the age of 60 and which may not benefit substantially from continued prostate cancer screening.

Following more than a thousand men, the researchers found:

Men with a PSA level above 2 ng/ml at age 60 should be considered at increased risk of aggressive prostate cancer and should continue to be screened regularly. Men with a PSA level below 1 ng / ml had a 0.2 percent chance of death from prostate cancer. The researchers concluded that men with PSA levels in this range, which is about half of all men, should be considered at low risk of prostate cancer death and may not need to be screened in the future.

In another study, Professor Philipp Dahm and colleagues at the University of Florida reviewed six trials, involving 387,286 participants. They found that PSA screening aids in the diagnosis of prostate cancer at an earlier stage, but does not have a significant impact on mortality, and comes at the risk of over-treatment.

The authors say there is insufficient evidence to support actively inviting all men in certain age groups to attend screening for prostate cancer (as happens with breast cancer screening for women), and they suggest men should be better informed about the uncertainties associated with screening.

What to do? Science Daily quotes Gerald Andriole, Chief of Urologic Surgery at Washington University School of Medicine. He suggests that PSA testing should be tailored to individual risk.

He recommends that young men at high risk of prostate cancer, such as those with a strong family history and higher baseline PSA concentrations, should be followed closely, while elderly men and those with a low risk of disease could be tested less often, if at all. "Approaches such as these will hopefully make the next 20 years of PSA based screening better than the first 20," he says.

You need to have a heart to heart with a doctor you trust, and if you don't like what you hear or feel it is incomplete or that you are being rushed into a decision, get a second opinion. This is one of those conditions that requires the patient to make decisions, and you might as well get educated now, before any alarms go off.