Last year, 218,000 men were diagnosed with prostate cancer, but nobody can tell them what type of treatment is most likely to save their lives.
Those are the findings of a troubling new report from the Agency for Healthcare Research and Quality, which analyzed hundreds of studies in an effort to advise men about the best treatments for prostate cancer. The report compared the effectiveness and risks of eight prostate cancer treatments, ranging from prostate removal to radioactive implants to no treatment at all. None of the studies provided definitive answers. Surprisingly, no single treatment emerged as superior to doing nothing at all.
“When it comes to prostate cancer, we have much to learn about which treatments work best,” said agency director Carolyn M. Clancy. “Patients should be informed about the benefits and harms of treatment options.”
But the study, published online in the Annals of Internal Medicine, gives men very little guidance. Prostate cancer is typically a slow-growing cancer, and many men can live with it for years, often dying of another cause. But some men have aggressive prostate cancers, and last year 27,050 men died from the disease. The lifetime risk of being diagnosed with prostate cancer has nearly doubled to 20 percent since the late 1980s, due mostly to expanded use of the prostate-specific antigen, or P.S.A., blood test. But the risk of dying of prostate cancer remains about 3 percent. “Considerable overdetection and overtreatment may exist,” an agency press release stated.
The agency review is based on analysis of 592 published articles of various treatment strategies. The studies looked at treatments that use rapid freezing and thawing (cryotherapy); minimally invasive surgery (laparoscopic or robotic-assisted radical prostatectomy); testicle removal or hormone therapy (androgen deprivation therapy); and high-intensity ultrasound or radiation therapy. The study also evaluated research on “watchful waiting,” which means monitoring the cancer and initiating treatment only if it appears the disease is progressing.
No one treatment emerged as the best option for prolonging life. And it was impossible to determine whether one treatment had fewer or less severe side effects.
Many of the treatments now in widespread use have never been evaluated in randomized controlled trials. In the research that is available, the characteristics of the men studied varied widely. And investigators used different definitions and methods, making reliable comparisons across studies impossible.
“Investigators’ definitions of adverse events and criteria to define event severity varied widely,” the report notes. “We could not derive precise estimates of specific adverse events for each treatment.”
The report findings highlighted by the agency include:
- All active treatments cause health problems, primarily urinary incontinence, bowel problems and erectile dysfunction. The chances of bowel problems or sexual dysfunction are similar for surgery and external radiation. Leaking of urine is at least six times more likely among surgery patients than those treated by external radiation.
- Urinary leakage that occurs daily or more often was more common in men undergoing radical prostatectomy (35 percent) than external-beam radiation therapy (12 percent) or androgen deprivation (11 percent). Those were the findings of the 2003 Prostate Cancer Outcomes Study, a large, nationally representative survey of men with early prostate cancer.
- External-beam radiation therapy and androgen deprivation were each associated with a higher frequency of bowel urgency (3 percent) compared with radical prostatectomy (1 percent), according to the 2003 report.
- Inability to attain an erection was higher in men undergoing active intervention, especially androgen deprivation (86 percent) or radical prostatectomy (58 percent) than in men receiving watchful waiting (33 percent), according to the 2003 report.
- One study showed that men who choose surgery over watchful waiting are less likely to die or have their cancer spread, but another study found no difference in survival between surgery and watchful waiting. The benefit, if any, appears to be limited to men under 65. However, few patients in the study had cancer detected through P.S.A. tests. As a result, it’s not clear if the results are applicable to the majority of men diagnosed with the disease.
- Adding hormone therapy prior to prostate removal does not improve survival or decrease recurrence rates, but it does increase the chance of adverse events.
- Combining radiation with hormone therapy may decrease mortality. But compared with radiation treatment alone, the combination increases the chances of impotence and abnormal breast development.
The most obvious trend identified in the complicated report is how little quality research exists for prostate cancer, despite the fact that it is the most diagnosed cancer in the country.
Studies comparing brachytherapy, radical prostatectomy, external-beam radiation therapy or cryotherapy were discontinued because of poor recruitment. Two ongoing trials, one in the United States and one in Britain, are evaluating surgery and radiation treatments compared with watchful waiting in men with early cancer. Other studies in progress or development include cryotherapy versus external-beam radiation and a trial evaluating radical prostatectomy versus watchful waiting.
“Successful completion of these studies is needed to provide accurate assessment of the comparative effectiveness and harms of therapies for localized prostate cancers,” the study authors said.
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From 1 to 25 of 179 Comments
My 92-year-old father is dying of prostate cancer. He will most likely not live to see his 93rd birthday this August. When first diagnosed 10 years ago (following a routine PSA test), he was told by his doctor, “Don’t worry, these things are so slow-growing, you will die of something else long before the cancer kills you.” He was given Lupron shots for several years until they became ineffective. A couple of years ago, after the cancer had spread into his spine, he was given external radiation treatments. Now the cancer is in all his bones, and, in unrelenting pain, he is hoping for death to come soon. He wonders, if he had had surgery at the time the cancer was first discovered, he might indeed have been able to die of “something else.” Considering that he still has no other serious health issues, I suspect that is the case. He might have lived to be a centenarian.
— V. RitschardHaving undergone radical prostatectomy rather pragmatically than thoughtfully, I now wish that I had done things differently. My life has been a nightmare of incontinence and erectile disfunction. I should have let nature take it’s course.
From TPP — My recent column and blog post on sex after prostate cancer surgery elicited many similar responses. To read more, click HERE
— richIt will be very helpfull to readers if the simtoms of postarate cancer are highlited
Kulkarni,INDIA
from TPP — Often prostate cancer is detected early when there are no symptoms. for a link on symptoms that can occur with later-stage prostate cancer, click HERE
— venkat kulkarniFrequent urination, erectile dysfunction and blood in the urine can be symptoms, but those can be symptoms of a number of less serious complaints as well.
Of course, the 92 year old given surgery as an 82 year old might have died on the table at 82 or had six years of incontinence before dying of an unrelated heart attack at 88.
— johnActually, in most cases your surgeon makes the decision for you. In my case with a very low PSA score I was railroaded for radical prostatectomy: and the result, at the age of 60, is total impotence and partial incontinence! Of course, my surgeon collected $20,000 fee for the surgery and the famous hospital in which the surgery was performed enriched its bottom line by $72,000.
I was poorly advised, realizing the situation I tried to read all what is written about prostate cancer and read four books. Albeit well meaning, testimonials and the scare stories pushed radical treatments and the surgery first. My urologists office staff at every visit spoke of “metastasizing” prostate cancer in a chorus even though I had a PSA level of 8.1. I believe scare tactics were used to make the radical surgery acceptable to me.
Prostate cancer treatment should be determined by many existing circumstances: including the patience’s age, sex life, and marital status. After a radical prostatectomy often patience sex life is over unless he agrees to receive implants and the like.
If an asexual life is OK with you, you rather be alive but asexual you better weigh your options well, and get emotional support of a partner or a close person to you.
— A. M. KeloWith all due respect to the subject at hand, I can’t help but think that the next “blog” I will see mentioned somwhere, will involve a discussion of whether or not people put the toilet paper over or under–and the pursuant discussion thereafter. It could also be a network reality series.
From TPP — Im confused by this comment given the serious nature of this particular post.
— Philip CI am 54 years old and was diagnosed with prostate cancer alomst 4 years ago as a result of a PSA test. Since then I have undergone two treatments: radical surgery and external beam radiation therary when the PSA began to rise again. It is my belief that, had I not had the original test, I would most likely be dealing with bone cancer today.
I question the comment on “overdetection and overtreatment” in the agencies report.
With respect to detection, I think it is fair to say that earlier testing can detect disease or establishes baseline PSA levels that can aid in decision making on the results of future tests. While prostate cancer is generally slower growing, the cancers that are detected earlier are often the more agressive variants that can be sucessfully dealt with sooner rather than later.
At the end of the day the patient (and his family) must make a treatment choice based on the best evidence available. There are no certainties in dealing with cancer and the decision involvies weighing up probabilities - you are betting with your life. You pit your life expectancy against the potential rate of cancer growth. The treatment side effects enter as secodary variables. The status quo of normal functions vs life with potential issues vs when you think the disease will metastitize and become painful and fatal. Many choose the watchful waiting option to defer making this choice and maximize their period of normalcy.
I challenge the concept of “over treating” the disease. This has a negative connotation. There are more, and less invasive, options now available and men are taking advantage of these to deal with thier cancers. How can this be a bad thing?
From TPP — Because many men are being rendered impotent and incontinent by treatments that may or may not be necessary.
— M MaydanMy brother was diagnosed with prostate cancer at age 47. I had suspected it the year previously when his PSA test came back below 4 but still in positive numbers. He read books, we spoke to friends and doctors. Radical protatectomy seemed the best procedure. However, the high rate of impotence was NEVER made clear, definitely not by the surgeon. I’m glad he had the surgery, I feel we have the best chance for the cancer to be completely removed. I wish, though, that this depressing side effect of ED would not have been a surgical outcome. It affects his quality of life.
— Susanposter number one — help you father ask for pain medication. (demand it). my dad had awful pain from metastatic prostate Ca and it took a lot of work to get his doctor to get him adequate relief. Finally got him on a fentanyl patch and then we switched physicians to a family practice doc who helped him feel better (ie supported) about increasing the dose and working out a plan for breaktrough pain. Transdermal is great because it means the patients don’t have to keep their eye on the clock. At some point the oncologist and the urologist may not be that helpful any longer, but anestheiologist / pain specialists provide a great service. We met with the physician and asked him if he could recommend someone who could help my father with evolving pain issues, or if he felt comfortable helping him, and he said “I’d be honored” and that was that.
So thanks again Dr Moon. And thank you all who work in hospice, can’t thank the hospice folks enough.
I can’t comment on the surgery vs waiting issue. hindsight is not 20/20, where cancer is concerned. looking therough the retrospectoscope I dont know if my family made the right decision, but the urge is always to take the cancer out, so we would certainly do it again. Don’t beat yourselves up!
Pain control is a no brainer — and inadequate pain control should not be tolerated. All the best to everyone
— SusanI’m 42 years old and African-American (i.e. at higher risk for prostate cancer than most Americans). My father died from prostate cancer in 2006 after living with the disease for 10 years. It saddens me to realize that 1) there is no recommended course of treatment that is better than any other and 2) my father was one of the unfortunate 3 percent. He initially had radiation treatments and his PSA was low for years. Then the cancer spread and his PSA shot up. He was being treated with chemotherapy and hormone therapy until his doctors determined that his options were closing. He died at home with hospice care. Even though he was technically a cancer survivor having lived with the disease in remission for more than 5 years, he was constantly worried about his PSA before and after every doctor visit over those 10 years. He had decent quality of life really but little peace of mind.
— SeanAre there are studies that compare the side effects of radical prostatectomy with robot assisted radical prostatectomy?
From TPP: Yes there are studies that compare the two. There’s no difference in terms of side effects (impotence, incontinence etc.) What matters the most is the experience of the surgeon whether it’s a robotic or open procedure. I know there is some data being presented on this in the spring at the national urology meeting. There was a study comparing consecutive surgeries at two major institutions, one surgeon did open and one did robotic. Erectile function results were the same. One important difference that emerged was shrinkage (in penis length) There appeared to be a loss with the open procedure and not with the robotic, but the difference may be explained by different techniques in measuring. The review article from today also looked at differences in recovery between the two types of surgery. Here’s what the review article says: Two studies with median follow-up periods of 30 and 67 months reported that overall survival was similar between laparoscopic radical prostatectomy and robotic-assisted radical prostatectomy. No differences existed between treatments in terms of PSA relapse; however, estimates were wide and ranged from 28% lower to 90% higher with laparoscopic radical prostatectomy . Wound healing was better with laparoscopic radical prostatectomy compared with open radical prostatectomy. Robotic-assisted radical prostatectomy and open radical prostatectomy had similar reintervention rates. Length of hospital stay was shorter after robotic-assisted prostatectomy than open radical prostatectomy (median, 1.2 vs. 2.7 days)
Finally, are you considering this procedure? Experience of the surgeon counts the most. But in terms of your recovery of erectile function, it depends on your age, if the tumor is contained and if you have an active sex life now without need for erectile function drugs. I just wrote about this issue in “On Sex After Prostate Cancer, Confusing Data.” To read the column, click HERE. I’d also encourage you to read the many reader comments that followed this story. Click HERE.
— BobI don’t understand comment 6, either, as this is a very important topic. I wonder if some of the uncertainty about over treatment and early detection doesn’t also apply to breast cancer.
— kalebergI’m surprised there is no direct mention of Proton Radiotherapy in the article. Several people I know have mentioned it’s effectiveness on treating prostate cancer. http://www.protonbob.com/proton-treatment-homepage.asp
I would like to hear people’s thoughts on this treatment modality
From TPP — Isn’t that the same thing as external beam radiation therapy? The report does include proton beam therapy, and concluded there was no evidence to show its superior. the numbers in parenthesis represent the original citations, which can be found in the report.
Proton-Beam Radiation Therapy
Several nonrandomized reports from 1 center of excellence provided clinical outcomes after combined proton-beam and photon radiation therapy (53–57). Between 86% and 97% (54, 57) of men were free of disease at the end of follow-up, and 73% to 88% did not have biochemical failure (53–56). Two percent to 8% had distant metastases (54, 57).
— TimothyI wonder what causes the issue of incontinence after
— Mr.radiotubeProstrate cancer surgery.
I am wondering if there is a bladder sling surgery that can be used as effectively on Men as it works on
Females?.
Until there is a durable and replicable treatment protocol for prostate cancer, experience from peers is the best guide for the newly diagnosed man. Peer support and experience may be the most durable decision making laboratory for men diagnosed with prostate cancer. Meeting every week for the last ten years, the Malecare support group here in NYC provides both a dialogue and a neural network mirroring the treatment choice making process that takes place between patient and MD. Significantly this peer supported choice making creates a sense of empowerment. No matter what the outcome may be, men who take time to learn and take to heart the variety of treatment options, tend to avoid the emotional pain that often accompanies a post treatment reoccurrence.
— Darryl Mitteldorf, http://www.malecare.comRe:AM Kelo (poster #5): My husband is a radiation oncologist and would completely agree with you that in some cases patients are being pressured to undergo surgery. Patients often get their diagnosis via the urologist (who does the biopsies). A urologist is a surgeon and surgeons want to operate. As a patient you should demand a consultation with a radiation oncologist to discuss other treatment options so you can make an informed decision that’s right for you. Unfortunately, because of their desire to operate, urologists may not make the referral unless you specifically request it.
— west coast MDI am 45 years old and a pathologist. I refuse to have a PSA test for some of the following reasons 1) Pure and simple fear an abnormal result will come back. I realize most elevated results are in the context of benign prostate conditions, but even then the uncertainty of what an abnormal result implies can have overwhelming psychological impact. An abnormal result may mean months (years?) of fear, perhaps for nothing 2) Although I am playing what many might consider to be the crapshoot of hoping to “die with rather than of prostate cancer”, the fact is I will indeed die with it from a statistical point of view. 3% odds are pretty good in my mind. 3) I do many autopsies and regularly take samples for microscopic examination of the prostate of men dying of something else eg heart attack or lung cancer. It is amazing how often cancer is present in these “random” samples. I would say in the order of 30- 50% in men over 60. They do indeed die with their prostate cancer.
— Andrew MitchellMy “bottom line” is that I respect men who undergo a PSA screening program for prostate cancer because it takes nerves of steel-which I don’t have- to deal with whatever result comes back. I am banking on those 3% odds to see me through- time will tell.
To #14, most incontinence after prostatectomy is caused by sphincter deficiency (”stress incontinence”) and less commonly urge-related causes.
Sling procedures have been shown to be effective in improving post-prostatectomy incontinence, though it is too soon to assess the durability of this response. It also appears to be more appropriate in men with milder degrees of leakage.
Prevention is the best treatment for incontinence and this is best accomplished by seeking out experienced, preferably fellowship trained surgeons, especially for robotic surgery where there are many surgeons offering this operation for which they are not formally trained and have minimal experience.
— TNCBy the way, concerning #5 AM Kelo-
The average reimbursement for to the surgeon by Medicare and most private payers is $1200 or so. This includes your preoperative counseling visit, operation, hospital days, and 90 days post-operatively. If your surgeon received $20,000 for a radical prostatectomy, it is almost certainly because you paid out-of-pocket or he is an out of network surgeon.
At this reimbursement rate, there is very little financial incentive for most urologists. One can make significantly more money with small procedures in the office.
Certainly there is a great deal of overtreatment for prostate cancer; however, given our current scientific capabilities, we are unable to predict who will benefit from treatment and who will die of something else first. The medicolegal environment in this country also contributes to the overtreatment problem. You might be the first in line to sue your doctor had he recommended a “watchful waiting” strategy and had you developed metastasis.
No one in this country should feel railroaded into treatment. Your surgeon should present all of the options to you, discuss the relative risks and benefits and help you come to a decision.
— PhillyurologistIf you have to ask if Proton radiation is the “same” thing as photon radiation as delivered by IMRT, you need to go to the listed web site and educate yourself on the very significant differences between the two. While there may not be statistical evidence (yet) of the superiority of Protons, to a man the patients treated at Loma Linda in CA will tell you that in their mind they have received the best treatment possible for their prostate cancer. I know as I am one of the patients. 54 years old and in the 4 months since treatment my PSA has dropped from 5.7 prior to treatment to 1.1 at the end of January 2008.
To answer post number 14, incontinence is the result of cutting the urethra to remove the prostate and then re-attaching it. In the process nerves to the bladder sphincter are damaged and in some men function is never restored.
— John WelchI am a 58 year old who recently discovered through PSA screening and a subsequent 8 needle prostate biopsy, that I have prostate cancer (Gleason Score 6 & a T1C). My father died from prostate cancer at the age of 67 before there was such a thing as PSA testing, and there is certainly evidence today of a genetic link.
My initial inclination was to undergo a radical prostatectomy. Cut It Out! My urologist certainly pointed me in that direction. I proceeded to read extensively on the topic. I interviewd a top radiation oncologist and a top (robotic) surgeon. Both acknowledged the probability (but no guarantee) with my stage of diagnosis that I could take some time to decide on a course of action before they would think that a radical local procedure was essential. Further study revealed that the 10 year survival rate, and for that matter the 15 year survival rate according to some well documented and published studies is no better for prostate surgery, radiation or watchful waiting (no prostate localized procedure) +/- 1-3%. That’s a pretty amazing statement!
I’ve since learned more, and have embarked on a serious effort to starve my prostate cancer of fuel through implementation of a rigid macrobiotic diet. In a day, I cut out animal protein (except modest intake of fish), all dairy products, caffiene, eggs and hydrogenated vegetable oils. I do not smoke, nor do I consume alcohol or drugs. Color me motivated! The side benefits of this are amazing. I’ve reduced my weight by almost 10%. I no longer need to take blood pressure medication. I am sure that my next blood work will reveal that my cholesterol has dropped considerably. My belly fat has melted away, and I get many comments on how trim I look. I am more energetic. I have started to excercise more. The initial BPH type symptoms that I had (urinary urgency and frequent urination at night) have improved dramatically. I embarked on this course with the logical arguments for it posed by Roger Mason in his book “The Natural Prostate Cure” (download via http://www.youngagain.org or available on Amazon and elsewhere). I have come to believe that it is within the realm of possibility to recover from prostate cancer; or to get into remission through diet. I’m intent to prove my approach with the desired results in a year’s time. Wish me well.
Technically, my regime, from those listed in the article is the one termed “Watchful Waiting”. But mine is not a passive process, and with my dietary approach and close monitoring, “Active Surveilence” is the more appropriate terminology.
If you or a loved one have a diagnosis of Prostate Cancer it’s imperative to learn as much about it as possible before having any radical local procedure (imo), all of which have substantial risks associated with them and dubious surety of improved outcome. Read the John Hopkins Prostate White Paper for a good overview. Read Dr. Peter Scardino’s Prostate Book. Read Dirk Benedict’s “The Confessions of a Kamakazie Cowboy”, Read Roger Mason’s Prostate book and his “Zen Macrobiotics for Americans”. Read the published studies. Learn just the right questions to ask and ask them. Be proactive!
— SonarmanI am a widow and advocate who has been active in education and working to solve many of the problems that men and women dealing with the realities of prostate cancer experience. I hope that the men who choose to not get regular PSA’s do not eventually develop a deadly prostate cancer. It is not a very good way to die. I would not wish a prostate cancer death on anyone. I have lost many friends to this horrible disease. Some have died way too young. It is the second highest cause of cancer death in men. Medscape has an article today with the headline: American College of Preventive Medicine Does Not Recommend Prostate Cancer Screening With DRE, PSA
The funny thing they say at the end of the article: “# Prostate cancer trails only lung cancer as a cause of cancer-related mortality among American men, but survival rates are very good if prostate cancer is diagnosed as local disease.
# In the current recommendation, the ACPM concludes that there is insufficient evidence to recommend routine prostate cancer screening with either the digital rectal examination or PSA.”
Seems like a slight disconnect here. They do not recommend testing that they say could give a man a “very good” survival rate. How will men be diagnosed as local disease if they are not tested?
They want to wait until a large trial is completed. which will not be for many years. They seem to be willing to sacrifice men’s lives.
At the same time we are cutting back funding for research that could lead to the answers that men and their physicians need.
I just don’t get it.
Poster number 17 in my mind it takes nerves of steel to not be tested if early treatment can give you a very good survival rate. The prostate cancer is the number 2 cancer killer and the most frequently diagnosed cancer.
— cancer widowTara-Parker Pope:
This report deserves the Pulitzer prize for ‘Communty Service Medical Reporting.’ Your approach and analysis is perfect.
Your procedure of treating the subject with actual
real life experiences, professional opinions, and comments beats any other approach to such a complex dilemma.
A. Gibson, III
From TPP — Thanks for your kind words. I think it’s a hugely important issue that deserves far more attention than it receives.
— Andrew GibsonI am really glad to read someone is addressing ways of stopping this cancer, #21. I’d like to add to your starving the cancer to death - AVOID SUGAR and artificial sweeteners like the plague! Cancer feeds on sugars.
What no one has addressed yet is “prevention” - a test doesn’t prevent anything, nor does finding something early.
I think it should be fairly common knowledge by now that we live in a chemical world and it is taking it’s toll on our health. I am VERY strongly in favor of eliminating toxins, providing REAL educational facts (not the garbage we’re conditioned to believe so some company can make a lot of money by manipulating facts and studies), and making industries stop pumping this garbage into our lives and bodies.
I am so fed-up with the toxic products AND food on the market that I could just scream!
For what it’s worth, I am lead to believe that most cancers cannot start or survive in an alkaline system. I don’t know all the details about this type of cancer - what I do know is that we are surrounded by poisons 24 hours a day and we need to do what we have to do to make it stop - it’s ruining the health of us and our kids.
Here are a couple links that I think are helpful and will contribute significantly to making things change: Choose Your Foods Like Your Life Depends on Them and Story of STUF
I wish you all well and like #21 said - “be PROACTIVE” - let’s fight like hell to get as many poisons out of our life and environment as possible!
— Evelyn VincentHello, such confusion is all the more reason for the medical system, which by the way is us; to establish what I call “possible pathways to prostate cancer”
Each bump in the road puts another “emotional card” on the stack. Another side effect? another card. Another development? another card. Pretty soon you might end up like me, a tumbled down pile of emotional cards.
Why not work off a check list when with patients? So when you go over the dizzying array of options; at least it’s in writing, you know, they know what you went over. EACH SURPRISE CREATES ANOTHER DENT in your WELL BEING
Have it go from simply cancer, to spread into my Thoraric spine and you might have an emotional breakdown. Did anyone say it could go to your BRAIN next? NO, but after wanting more Surprises, I read that and wasn’t in shock when they did an MRI of my brain.
GET TOO UPSET? and your hospital WILL TOSS YOU OUT THE DOOR such as mine did, Dartmouth Hitchcock Medical Center in Lebanon, NH, yes the famed Dartmouth College Medical School
There’s lots to be careful about, don’t believe all you read. AND AT THIS POINT, BEING 55 WITH STAGE IV DO YOU REALLY THINK I CARE WHO KNOWS WHAT ANYMORE?
— Gregory Giro Burlington Vt