Watch and Wait, or Not: Studies weigh risks of delaying prostate surgery

Two long-running studies of men with prostate cancer have partly clarified the risks of postponing treatment of the disease. A wait-and-watch approach increases some men’s odds of premature death, compared with the odds in men who opt for prompt surgical removal of the prostate, researchers find. On the other hand, so-called watchful waiting is a gamble that can pay off for men whose tumors remain dormant or who are relatively old when they’re diagnosed.

Each year, nearly 250,000 men in the United States learn that they have prostate cancer, and about 30,000 die from the disease. Deciding how aggressively to treat the cancer is difficult, because many prostate tumors aren’t lethal, and surgery and alternative therapies frequently cause side effects.

Surgery is an “investment” that often comes with immediate costs, including impotence and incontinence, says urologist Anna Bill-Axelson of Akademiska Hospital in Uppsala, Sweden. She and her colleagues began a trial in 1989 to quantify surgery’s dividend in terms of prolonging life.

The researchers recruited nearly 700 men who had just been diagnosed with prostate tumors, were less than 75 years old, and were healthy enough, aside from the cancer, to live at least 10 more years. Half the volunteers underwent prostate surgery, and half agreed to watchful waiting, which involved periodic testing to monitor the tumor for signs of growth.

Ten years later, 10 percent of the men who’d had surgery and 15 percent of the watchful-waiting group had died from prostate cancer. In both groups, 17 percent of the men had died from unrelated causes, the researchers report in the May 12 New England Journal of Medicine.

According to internist H. Gilbert Welch of the Veterans Administration (VA) Medical Center in White River Junction, Vt., the findings apply mainly to men of an age and health level fitting the criteria of the study and whose tumors are large enough for a doctor to feel. “There is a benefit to surgery in these patients,” he says. However, most U.S. men are diagnosed with tumors detectable only by prostate-specific antigen (PSA) testing, a sensitive screening method that Swedish physicians don’t routinely use, Welch notes.

Given that PSA-detected tumors that are too small to feel may never become life threatening, the benefit of surgery is likely to be lower in the United States than it was for the men in the Swedish study, according to Timothy J. Wilt of the Minneapolis VA Medical Center. He adds that data from the study suggest that men over 65 don’t benefit from surgery, even in Sweden.

The new results support the use of surgery in some cases of prostate cancer, comments biostatistician James A. Hanley of McGill University in Montreal. But since surgery’s benefits were slight in the study, he says, “the incontinence and the impotence from the surgery have to be weighed.”

Hanley adds that surgery is probably best for men who have many years to live and whose tumors appear likely to spread. In a separate study, he and two colleagues analyzed data on 767 Connecticut men who were diagnosed with prostate cancer in the 1970s and 1980s and who opted to not have surgery. In the May 4 Journal of the American Medical Association, the researchers report that men with low-grade tumors faced a minimal risk of dying from prostate cancer within 20 years.