Surgery Unnecessary for Early-Stage Prostate Cancer

Results of a 20-year follow-up study among men with localized prostate cancer suggest that surgery is not associated with significantly lower all-cause or prostate-cancer mortality than observation.

Researchers at the Minneapolis Veterans Administration (VA) Health Care System (MN, USA), Washington University School of Medicine (WUSTL; St. Louis, MO, USA), and other institutions reported the most recent results of the prostate cancer intervention versus observation trial (PIVOT), which randomly assigned 731 men with localized prostate cancer to radical prostatectomy or observation from November 1994 to January 2002. Follow-up was extended through August 2014 for all-cause mortality and prostate-cancer mortality.

The results showed that during 19.5 years of follow-up, death attributed to prostate cancer or treatment occurred in 27 men (7.4%) assigned to surgery and in 42 men (11.4%) assigned to observation. Surgery was associated with lower all-cause mortality among men with intermediate-risk disease, but not among those with low-risk or high-risk disease. Treatment for disease progression was less frequent with surgery than with observation, and was primarily for asymptomatic, local, or prostate-specific antigen (PSA) progression. Urinary incontinence, erectile, and sexual dysfunction were each greater with surgery than with observation. The study was published on July 13, 2017, in the New England Journal of Medicine (NEJM).

“About 70% of patients newly diagnosed with prostate cancer cases are in the early stages, meaning the cancer is confined to the prostate gland, and they have nonaggressive tumors. As such, these patients have an excellent prognosis without surgery,” said study co-author Professor Gerald Andriole, MD, director of the WUSTL division of urologic surgery. “We hope the findings will steer doctors away from recommending surgery or radiation to their patients with nonaggressive early-stage prostate cancer and patients away from thinking its necessary.”

“However, the data show that surgery may have a mortality benefit in some men, particularly those with a long life expectancy and intermediate-risk prostate cancer. It would be a disservice to dismiss surgery as a viable option for patients with intermediate-risk prostate cancer,” concluded Professor Andriole. “For these patients, and for some men with high-risk prostate cancer, surgery is often beneficial, as are other treatments such as radiation.”

Observational strategies include active surveillance (AS), which involves close follow-up after diagnosis, typically with serial PSA testing, digital rectal exam, and prostate biopsies; and watchful waiting (WW), which refers to a strategy of observing patients without monitoring and providing palliative care when prostate cancer becomes symptomatic. AS is recommended for the 30% of men who will eventually require treatment for prostate cancer, while WW is historically reserved for men with less than 10 years' life expectancy or major comorbidities, and who are not expected to die of prostate cancer.

Related Links:
Minneapolis Veterans Administration
Washington University School of Medicine