"Watchful waiting" isn't best option for prostate cancer, study argues
The Washington Post
WASHINGTON — A large new study is challenging the common practice of recommending that older men forgo treatment for early prostate cancer and instead wait to see whether the malignancy progresses.
The study of more than 44,000 American men ages 65 to 80 found that those who chose to treat their prostate cancer aggressively with surgery or radiation were about 30 percent less likely to die than those who waited, indicating that treatment offered a clear advantage.
The research, published in today's Journal of the American Medical Association, is the first to directly examine what has become conventional wisdom: that many older men need not treat early prostate cancer because it tends to grow so slowly that they will probably die of something else first.
"For many years, the thinking has been that observation, or 'watchful waiting,' was the safest option for elderly patients with early prostate cancer," said Dr. Yu-Ning Wong of the Fox Chase Cancer Center in Philadelphia, who led the study. "This suggests there may be a benefit of treatment, even in this age group."
The findings prompted debate among specialists, who said the results could have potentially far-reaching implications because they address one of the central quandaries about prostate cancer and because the disease is so common. It strikes 235,000 U.S. men each year and kills more than 27,000, making it the most common cancer and second leading cancer killer, after lung cancer, among men. Most cases are diagnosed after age 65.
The widespread use of the prostate-specific antigen (PSA) screening test to catch prostate cancer early has led to intense debate about how aggressively to treat the disease. Some doctors fear the cancer is being overtreated, particularly in older men, subjecting them to therapies that leave many impotent and incontinent when their cancer would never bother them if it was left untreated.
While some recent studies have produced evidence supporting aggressive treatment for younger men, none had directly addressed the question in older men.
Some experts said they hoped the new findings would encourage more doctors to consider treating older men.
"This debunks the idea that older men do not benefit from treatment," said Dr. Christopher Amling, a professor at the University of Alabama, Birmingham. "This gives support to the idea that active treatment can be beneficial."
Others experts, however, expressed skepticism, saying the study's design may have missed another explanation for the lower death rate among men who were treated: They were probably healthier in ways that doctors can tell only by examining them in their office, not from looking at their medical records, which is what the study's authors did.
"There was probably something about these guys that made them more likely to get treated that also made them more likely to survive," said Dr. Mark Litwin of the David Geffen School of Medicine at UCLA, who co-authored an editorial accompanying the paper.
Wong acknowledged that the study's design had limitations, making it important that the findings be confirmed by additional research. But she said she and her colleagues analyzed the data carefully to take into account factors that could have influenced the findings, such as the subjects' ages and other health problems.
"We adjusted for as many of those differences as we could," Wong said.
Wong and her colleagues analyzed data collected for a Medicare database of about 44,630 men diagnosed with early prostate cancer. The researchers followed the men until 2002, comparing the death rate of those who opted for watchful waiting with those who had their prostate glands removed or underwent radiation treatment within six months of their diagnosis.
Overall, those who were treated had about a 30 percent lower risk of death during the 12 years of follow-up, the researchers found after taking other factors into account. Even the oldest men, those 75 to 80, were 27 percent less likely to die, they found.
Wong noted that other advances in medicine have enabled men to live longer, relatively healthier lives than in the past, extending the age at which men might make good candidates for treatment.
"They teach us in medical oncology not to practice ageism," Wong said. "As people are living longer and their other medical problems are stable, I think patients should at least consider treatment."
Advances in treatment have also minimized some of the side effects, she said, though each patient will have to weigh the risks and potential benefits.
Litwin noted that the side effects can be significant. "There is a quality-of-life cost that is often paid by undergoing treatment," he said.
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