Prostate cancer: Treatments may be avoided or delayed in many cases

• A new long-term study finds a 97% survival rate among men with prostate cancer at 15 years, regardless of whether the disease was treated or not.
• While it can be difficult to decide on one’s response when faced with a prostate cancer diagnosis, the study suggests that the decision need not be too frightening.
• Men who decided not to be treated experienced double the chance of eventual metastasis, but even that did not lower their rate of survival.

When a man is diagnosed with prostate cancer, he has two choices to make. He may choose to be treated or to keep a watchful eye on the often slowly progressing disease. If he selects treatment, he then must decide on the type of treatment that seems most suitable.

New research presented this month at the European Association of Urology (EAU) Congress in Milan, Italy reports the results of a study comparing the outcomes associated with each of these choices. The study is the longest-running of its kind.

The study found that 97% of men diagnosed with prostate cancer remained alive at the end of the 15-year study, regardless of whether they were treated or the type of treatment they received.

While the course of their disease varied somewhat depending on their decision, even men whose cancer had metastasized survived.

The study tracked 1,643 men in the United Kingdom aged 50–69 years who were diagnosed with prostate cancer between 1999 and 2009 based on the results of a PSA blood test.

As part of the study, participants agreed to be randomly assigned to actively monitor their disease, radical prostatectomy surgery, or radical radiation-based therapy.

The study appears in the New England Journal of Medicine.

Prostate-specific antigen testing

The PSA or prostate-specific antigen blood test itself is somewhat controversial.

The study’s lead author, Dr. Freddie Hamdy, explained that PSA tests “can be followed by a snowball of further testing, including biopsies of the prostate.” If cancer is found, he said, it is likely localized and low risk.

“With this testing,” Dr. Hamdy warned, a ‘healthy’ man can become a ‘cancer patient’ unnecessarily.”

With this in mind, the U. S. Preventive Services Task Force on Prostate Cancer recommended about a decade ago that physicians stop including PSA screenings in checkup bloodwork. Since then, however, diagnoses of advanced prostate cancer detected by other means have significantly increased, and many physicians have resumed ordering PSA tests for their patients.

Options for people with prostate cancer

Prostate cancer most often — though not always — progresses slowly, taking many years to spread or metastasize beyond the prostate.

The three most common medical responses to a diagnosis of prostate cancer are:

• active monitoring — in which the cancer is closely monitored through PSA testing and regular prostate biopsies, moving to active treatment only if symptoms arise or cancer grows.
• radical prostatectomy — in which the entire prostate, and presumably cancer, is removed.
• radical radiotherapy — the prostate is treated with radiation to kill cancer.

Both radical prostatectomy and radical radiotherapy are frequently accompanied by lifestyle-altering adverse effects, such as erectile, urinary, and bowel dysfunction.

The new study found that adverse effects from prostatectomy and radiation can last 12 years or more.

“Nowadays, it’s not just radiation or surgery that are the options,” noted Dr. Adam Ramin, who was not involved in the study.

“The advantage of that is that in many instances we can actually convert prostate cancer into a chronic disease, you know, just like diabetes or hypertension,” Dr. Ramin said.

He noted that there are many men who may be good candidates for a treatment option called focal therapy. Focal therapy targets cancer through various means, including high intensity focused ultrasound, cryotherapy, laser ablation, and photodynamic therapy.

While the study found that men who opted for active monitoring were twice as likely to see it progress or metastasis, few of them died during the follow-up period.

Of the men who participated in active monitoring, cancer in 9.4% metastasized, compared to men who received a prostatectomy (4.7%) or radiation (5.0%).

For men whose cancer metastasizes, Dr. Ramin reported that while chemotherapies have not changed much over the years, there have been advances in hormonal manipulation-type therapies or androgen suppression therapies.

“Ten, 15 years ago, we only had one or two different kinds of hormone therapies,” he said. “Now, there’s a whole slew of them which work through different mechanisms.”

Dr. Benjamin H. Kann, also not involved in the study, added:

“New systemic therapies helpful for the metastatic disease include (177)-lutetium-PSMA-617, a radiopharmaceutical that selectively attaches to a specific protein on prostate cancer cell surfaces and destroys the cell.”

Deciding on prostate cancer treatment

“The two most important factors are what we call the stage and the grade of the cancer, and how advanced the cancer is great means how aggressive the cancer is,” said Dr. Ramin.

Dr. Ramin noted that molecular studies performed on biopsied tissue could provide better prognosis indicators in assessing whether a person is a suitable candidate for active monitoring or not.

One of the study’s findings was that because of advances in diagnostic techniques, many of the men who were diagnosed as being at low risk of metastasis years ago would now be diagnosed at intermediate risk.

Dr. Hamdy told the EAU in a press release:

“It’s clear that, unlike many other cancers, a diagnosis of prostate cancer should not be a cause for panic or rushed decision-making.

Patients and clinicians can and should take their time to weigh up the benefits and possible harms of different treatments in the knowledge that this will not adversely affect their survival.”

Dr. Kann said another factor is the person’s overall health and apparent life expectancy: “Men with shorter life expectancies due to age or other significant health issues may be more appropriate to monitor.”

Beyond that, Dr. Hamdy told Medical News Today, the choice may depend on a man’s “priorities in life, their other medical conditions (if any) and fitness, and measuring the ‘trade-off’ between treatment benefits and potential harms, particularly with sexual function, urinary leakage, and bowel symptoms.”

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