Study raises prostate cancer surgery questions


LOS ANGELES – Most patients diagnosed with early stage prostate cancer will live just as long if they simply watch their cancers rather than have them surgically removed, according to the results of a landmark clinical trial that could upend the medical approach to a disease that affects 1 in 6 men.

The study, which focused on cancers confined to the prostate, should reassure patients who want to avoid potential side effects of surgery – such as urinary incontinence and sexual dysfunction – but still protect their lives, cancer experts said. If embraced by patients and doctors, the new information stands to radically change prostate cancer management in the U.S., where the majority of early prostate cancers are treated aggressively with surgery or radiation therapy.

The much-anticipated results of the so-called PIVOT trial, reported in today’s edition of the New England Journal of Medicine, did find that surgery provided a slight benefit for patients with higher-risk early cancers. That group included men whose blood levels of prostate-specific antigen, or PSA, were above 10 nanograms per milliliter or who had larger tumors with cells that were more abnormal in appearance.

And because the average age of the 731 men who participated in the trial was 67, with only 10 percent under age 60, the implications for younger men who have more potential years ahead of them are less certain, experts noted.

But overall, the clinical trial – the largest of its kind and the first in the era of widespread PSA screening – should be welcome news for men diagnosed with early prostate cancer, said Dr. Mark S. Litwin, chair of urology at the University of California, Los Angeles and a researcher at the university’s Jonsson Comprehensive Cancer Center.

“The trial gives us results that we have been waiting for in urology for quite some time,” said Litwin, who was not involved in the study. “It confirms many of the recent reports that men with prostate cancer, by and large, can be safely managed with close monitoring.”

Men in the trial were recruited from 44 Department of Veterans Affairs medical centers across the U.S. and eight medical centers. Patients were randomly assigned either to receive surgery or to forgo treatment and have their cancers followed with checkups every six months.

About half of the men – who were tracked for a median of 10 years – died during the course of the study. But the vast majority of these deaths were not from prostate cancer, the authors noted.

The likelihood of death from any cause was the same for patients who had surgery and those who didn’t.

Only 7.1 percent of men in the study died from prostate cancer or as a result of surgery to treat it, in statistically equal numbers in both groups.

“That’s a key point” that men should absorb, said Dr. Durado Brooks, director of prostate and colorectal cancers for the American Cancer Society. “When most men are told they have prostate cancer, their immediate thought is, ‘Oh my God, I’m going to die,’ and their immediate next step is, ‘Let’s do something about this.’ “ By then, Brooks said, “the idea of an observation approach is lost.”

Although all of the men had a diagnosis of early prostate cancer with no spread to the bones, there were differences in the seriousness of those cancers. Some of the tumors were larger, some men had higher PSA levels, and some had higher so-called Gleason scores, numbers assigned to cancers based on how abnormal the cells look under a microscope.

When higher-risk cancers were assessed separately, the authors detected a slight edge with surgery, most clearly in those men with PSA scores over 10 nanograms per milliliter of blood. Among these patients, death from any cause was 13 percent lower in the surgery group and death related to prostate cancer was 7 percent lower compared with the observation group.

For high-risk men, “surgery clearly has been shown to be beneficial over watchful waiting,” said study co-author Dr. William Aronson, a urologist at the VA Greater Los Angeles Healthcare System.


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