A study published in the New England Journal of Medicine is creating confusion for physicians and patients. The ProtecT (Prostate Testing for Cancer and Treatment) trial was designed to answer the question: Which treatment approach works best for prostate cancer that has not spread beyond the prostate gland?
What They Did:
UK researchers measured PSA (prostate specific antigen) levels in 82,429 men between the ages of 50 and 69 from 1999 to 2009. As a result of this testing, 2,664 were found to have localized prostate cancer, meaning that it was confined to the prostate gland itself and had not metastasized to other parts of the body. The scientists were able to recruit 1,643 to participate in the ProtecT study.
The men were randomly assigned to one of three groups:
Surgery (radical prostatectomy): 553
Radiation Therapy + hormone suppression: 545
Active Surveillance (watch and Wait): 545
The men were followed for a median of 10 years after diagnosis.
What They Found:
The good news was that most men (99%) survived at least 10 years no matter which group they were in. Of those who received radiation, 4 out of 545 died. In the group of men who had their prostate glands removed, 5 out of 553 died. In the group that was actively monitored 8 out of 545 died. There was no statistical difference between the three groups.
The quick conclusion from the data described above would be that “watchful waiting” is just as good as aggressive treatment. One might even determine that such active surveillance is best because it doesn’t lead to unpleasant complications such as incontinence, bowel problems or erectile dysfunction.
Digging Deeper into the Data:
Of the 545 men undergoing active surveillance, 291 needed “radical treatment” by the end of the study (142 underwent surgery, 146 received some form or radiation therapy and 3 had HIFU or high-intensity focused ultrasound therapy). In other words, more than half of the men in the watch-and-wait group ended up having aggressive treatment.
Perhaps more alarming was the observation that:
“A total of 204 men had disease progression, including metastases. The incidence was higher in the active-monitoring group than in the surgery and radiotherapy groups (112 men in the active-monitoring group, 46 in the surgery group, and 46 in the radiotherapy group. Evidence of disease progression included the presence of metastases (33 men in the active-monitoring group, 13 in the surgery group, and 16 in the radiotherapy group…”
What this means is that watching and waiting was more likely to lead to prostate cancer spread and ultimately more aggressive treatment with long-term testosterone deprivation.
The Bottom Line:
It is estimated that over 180,000 men will be diagnosed with prostate cancer this year and 26,120 will die. By contrast, the CDC reports that 220,000 women will be diagnosed with breast cancer and 40,000 will die. Those of us who have lost friends and family to breast or prostate cancer know that such statistics do not adequately reveal the pain and suffering these people go through.
When cancer metastasizes to distant locations it becomes much harder to treat. That’s why we were somewhat disappointed by the headline “No Evidence That Treating Early Prostate Cancer Makes a Difference.” While it is true that 10-year survival rates were the same among the three groups, over half of the men in the active surveillance group went on to have surgery or some form or radiation before the ten years were up.
The men in the watchful waiting group were more than twice as likely to experience disease progression and metastases compared to the men who initially received surgery or radiation. It will be interesting to learn what the survival rates are after 15 or 20 years to see what will happen over the long haul.
It is comforting to know that men do not have to rush into a decision about treatment. Active surveillance is a viable option, as long as a urologist is reading the tea leaves and being vigilant. What we desperately need, though, is a much better screening tool than PSA. This blood test does not distinguish between prostate cancers that will never pose a problem and those that should be treated promptly and aggressively.
Should you wish to listen to our one-hour interview with one of the country’s foremost breast cancer surgeons, Susan Love, MD, and one of the country’s experts on prostate cancer, Charles Myers, MD, we invite you to visit this link.
