Douglas Kelly, MD
Research published in the New England Journal of Medicine this month found significant differences between men with prostate cancer who were treated with surgery and those were monitored, which is called watchful waiting. During watchful waiting, doctors only intervene with hormone therapy drugs once the cancer has spread to the bones.
Of the 695 Swedish men participating in the study in the 1990s, the men in the surgery group seemed to fare better than those in the watchful waiting group after 26 years:
- Of the surgery group, 26% had their cancer metastasize to the bones and 56% died of any cause.
- Of the watchful waiting group, 38% had their cancer metastasize to the bones and 69% died of any cause.
The men in the surgery group had their prostates removed through a procedure known as prostatectomy. On the surface, it might seem like a no-brainer to choose to aggressively treat your prostate cancer instead of just watching it, right?
These study results, though, do not apply to men in the United States. The Swedish patients had more advanced cancer than what we typically see in the U.S. In addition, the Swedish study used watchful waiting, which is passive, rather than active surveillance. With active surveillance, doctors perform routine screenings and can start treatment if there are signs the cancer is growing.
Here are a few other statistics from the study that offer a caution about surgery:
- 41% of the surgery group reported urinary leakage versus 11% in the watchful waiting group.
- 42% of the surgery group still eventually required hormone therapy due to cancer progression, meaning surgery was not a guarantee of cure.
In the U.S., men are frequently diagnosed on the basis of a PSA screening test, and about 80% are considered to have early stage prostate cancer. Typically, these men don’t have symptoms and their Gleason score is most commonly a 6. In the Swedish study however, only 12% were diagnosed from PSA screening, many patients had already developed symptoms and the cancer looked aggressive under the microscope in about 30% of cases, with a Gleason score of 7 or higher.
Unlike in the Swedish study, doctors now use active surveillance, which is a far better way of following prostate cancer than watchful waiting. Patients under active surveillance get regular assessments with a PSA test, digital rectal exam, and sometimes MRI scans and repeat biopsies.
I have personally been a fan of active surveillance for many years, but it is not for everyone. In the Swedish study, 67% of men in the watchful waiting group eventually required hormone therapy while 33% did not, emphasizing that not all men with prostate cancer will require treatment. The trick is to determine who does and who does not need therapy, and to safely monitor those who choose active surveillance.
Fortunately, there are new tools available to help determine the risk of your cancer growing. Prolaris and Oncotype DX are two tests that examine DNA markers in your tumor to help determine whether the cancer is likely to progress or not. If you do choose active surveillance, I encourage you to use this time to adopt a healthy lifestyle with a focus on nutrition and exercise.
See our infographic about prostate cancer to learn more the disease.