Study Finds Some Prostate Cancer Patients Potentially Overtreated

For men with less aggressive prostate cancers, the balance between the risks and benefits of immediate treatment with surgery or radiation are not always well-defined. Research has shown that older men with lower-risk prostate cancer who choose so-called watchful waiting are likely to die from another cause during the first 20 years after their cancer diagnosis. Meanwhile, surgery or radiation to treat prostate cancer can lead to complications such as erectile dysfunction, urinary incontinence and bowel difficulties.

"Just as a failure to treat a potentially lethal prostate cancer is generally considered inappropriate from a quality-of-care perspective, overtreatment of lower-risk cancers is also not in the patient's best interest. For some men with early stage prostate cancer, surgery or radiation therapy may result in substantial negative effects without a survival benefit," says study author John T. Wei, M.D., M.S., associate professor of urology at the U-M Medical School.

The study appears in the Aug. 16 issue of the Journal of the National Cancer Institute.

Researchers looked at 64,112 men diagnosed with early stage prostate cancer, using the Surveillance, Epidemiology and End Results registry, a population-based cancer registry maintained by the National Cancer Institute. Men were divided into high-risk or low-risk categories, based on characteristics of their tumors. Among the 24,835 men with lower-risk cancers, 55 percent were treated with initial surgery or radiation, suggesting that aggressive treatment is quite common even among men where an expectant approach is a viable option.

The researchers found that, among men with lower-risk cancers, those under age 55 are more likely to be treated with surgery versus watchful waiting. In contrast, men aged 70-74 were more likely to be treated with radiation over watchful waiting. From 2000 through 2002, more than 13,000 men with lower-risk cancer received treatment with surgery or radiation within the first several months after diagnosis. Among this group, patients older than 70 with mid-grade tumors were most likely to receive potentially unnecessary surgery or radiation within the first year after diagnosis.

"There are many men with prostate cancer who will benefit from early treatment with surgery or radiation therapy. However, prostate cancer is not a one-size-fits-all condition and we now know that many men are diagnosed with slowly growing cancers that are unlikely to cause symptoms or be fatal. Given that the average patient often has bothersome side effects of surgery or radiation, it is important to evaluate the barriers to greater use of expectant management approaches including active surveillance, particularly among this reasonably large group of men with lower-risk cancers," says lead study author David C Miller, M.D., MPH, adjunct lecturer at U-M and now a health services research and urological oncology fellow at the David Geffen School of Medicine at UCLA.

"Based on data from this study, it is clear that the number of lower-risk patients who receive initial aggressive therapy is not trivial and we have to ask the question whether this is too much treatment for some of these men," Miller continues. "We should continue to explore our patients' preferences regarding the different treatments for early-stage prostate cancer and better educate them about the entire spectrum of options, including the appropriateness of initial active surveillance in many lower-risk cases."

The authors report that for many men with lower-risk cancers a potentially appealing treatment option is called active surveillance. Building on the traditional concept of watchful waiting, active surveillance involves frequent monitoring of the tumor without immediate active treatment. Active surveillance can help distinguish between more-aggressive and less-aggressive cancers thereby improving doctors' ability to identify the patients most likely to benefit from surgery or radiation.

Some 234,000 men will be diagnosed with prostate cancer this year, and 27,350 will die from it, according to the American Cancer Society.

In addition to Wei and Miller, U-M study authors are Stephen Gruber, M.D., Ph.D., associate professor of internal medicine, epidemiology and human genetics; Brent Hollenbeck, M.D., assistant professor of urology; and James Montie, M.D., Valassis Professor of Urologic Oncology and chair of urology.

Funding for the study was from the National Institutes of Health.

Reference: Journal of the National Cancer Institute, Vol. 98, No. 16.