New study compares surgery, radiation, and active surveillance in prostate cancer

A long-awaited study from researchers in the United Kingdom compares three major approaches: surgery (radical prostatectomy), radiation, and active surveillance (also known as ‘watchful waiting’) for men with localized prostate cancer diagnosed with prostate specific antigen (PSA) blood test, and has some eye-opening results.

The report, appearing in the New England Journal of Medicine, finds that after ten years, men undergoing either of the three approaches had similar, low rates of death from prostate cancer. Surgery and radiotherapy reduce the risk of cancer progression over time compared with active monitoring, but cause more side-effects. We asked Otis W. Brawley, M.D., chief medical officer, for his response to the study.

“This study tells us that prostate cancer detected by PSA grows very slowly. Only about 1 in 100 men diagnosed with prostate cancer using PSA died of prostate cancer over ten years, a mortality rate that was lower than what the authors expected to see.

Otis W. Brawley, MD, Chief Medical Officer, American Cancer Society

“The men in the study had the same mortality rate regardless of the treatment they received, even when that treatment was no treatment. This study has just ten years of data, and it may take 20 or 25 years to see survival improvements from treatment, so we cannot say yet with certainty whether and how much of an advantage treatment has over no treatment. We can only say that at ten years, there is no difference.

“Men who received treatment did have half the risk of cancer spread, known as metastatic disease, of men who were monitored carefully (~2.5%-3% of men receiving surgery or radiation versus 6% of men in active surveillance). But a significant proportion of the men whose cancer had spread had no symptoms.

“On the other hand, the men receiving treatment were more likely to have side effects, some of them serious, over the ten years; things like bowel, bladder, and sexual dysfunction. Men who were monitored carefully without treatment, of course, avoided those side effects. And if they showed signs of their cancer spreading, those men could and did get treated.

“We may eventually find out that treatment using radiation and surgery will reduce the risk of death from prostate cancer decades later. We will also need to carefully measure if it reduces death from other causes, as well, to get a full picture of the risks and benefits of treatment.

“This paper shows clearly that treatment, whether with radiation or surgery, can reduce the chances of metastatic cancer. But it also shows that observation, or active surveillance, is a reasonable option for men diagnosed with localized prostate cancer through PSA screening and especially for men diagnosed with low or moderate grade localized disease.

“As the authors point out, active surveillance and/or delayed treatment avoids the side effects from treatment in those who do not need treatment, but there is an increased risk of cancer progression and spread, and some symptoms may increase gradually over time.

“The American Cancer Society recommends men be informed of the potential risks and potential benefits of prostate cancer screening and treatment before making a decision about whether to be screened. This study will help inform that discussion for men making what is a highly personal, and often difficult choice.”