Introduction

Prostate cancer is the second-leading cause of cancer deaths in men in the USA. And with the availability of a simple blood test -- prostate-specific antigen (PSA) -- it's being diagnosed more often, and at an earlier stage. There's been some controversy about the best treatment for early prostate cancer. Some advocate surgery to remove the gland and the tumor, others believe different forms of irradiation are best, and a third group are in favor of what is known as 'watchful waiting'; this means doing nothing unless and until the cancer shows signs of spread within the body. (The reason for suggesting watchful waiting is that many prostate cancers grow extremely slowly, so that the patient dies of some other cause before the cancer becomes really problematic.)

A new study from Scandinavia comparing the long-term outcome after surgery (what's known as 'a radical prostatectomy') with that of watchful waiting has been published, and hailed as 'a landmark study'. Surgery was found to almost halve the numbers of death from prostate cancer, compared to watchful waiting. So it's important to know how relevant the findings are for men in the USA and other countries.

The Scandinavian study

Over a ten-year period, 695 Swedish men aged 60 to 70 with early prostate cancer were enrolled. They were allocated randomly to receive surgery, or to undergo 'watchful waiting'. The watchful-waiting group patients received no immediate treatment, but if symptoms occurred that indicated the tumor was enlarging (e.g. a weak urinary stream), this was treated by surgery or irradiation.

After an average follow-up period of 6.2 years, 16 (4.6%) of the 347 men who originally had surgery had died of prostate cancer, compared with 31 (8.9%) of the 348 men who were allocated to watchful waiting. In those who had surgery, the tumor had spread elsewhere in the body (metastases) in 35 men (10.1%), compared with 54 (15.5%) in the watchful-waiting group.

The overall death rate from all causes was not significantly different in the two groups. A total of 53 men (15.3%) who had surgery died, compared to 62 men (17.8%) in the watchful-waiting group. The study was probably not large enough to be able to show a significant difference in this respect.

Side effects during 4 years of follow-up

A questionnaire was used to record symptoms and signs involving sexual, urinary, and bowel function, as well as psychological factors, during the first 4 years of follow-up.

As regards sexual function, 80% of men in the surgery group had difficulty obtaining an erection, compared with 45% in the watchful waiting group. 'Distress' due to impaired sexual function was reported as moderate or great in 56% of the men who had surgery, and in 40% of the watchful-waiting men.

Urinary leakage was more common after surgery than with watchful waiting - 49% vs. 21%. On the other hand, symptoms of urinary obstruction were more frequent in the watchful-waiting men; a weak stream was reported by 44% of them, compared with 28% in the surgery group.

The side effects of each treatment approach were clearly different with respect to sexual and urinary function. However, any disturbances of bowel function, anxiety, depression, and well-being were similar in the two groups.

How relevant are the findings for other countries?

This thorough study shows that surgical treatment of early prostate cancer reduces the risk of death and distant spread of the cancer. The actual benefit may seem quite small; to prevent one death from prostate cancer over an 8-year period, 17 men would have to have the surgery.

However, the benefit seen in the Swedish study cannot be assumed to be the same in a typical US population. One reason for this is that the diagnoses in the study were made clinically - i.e. the tumors had grown enough to cause symptoms (e.g. difficulty with urinating), and ¾ of the patients had a palpable tumor on digital (rectal) examination; only 10% were diagnosed because of a raised PSA level. In the USA, on the other hand, ¾ of men diagnosed as having prostate cancer are found because of an elevated PSA. It's known that PSA screening detects tumors about 6 years before they would cause symptoms. So the Swedish patients were probably considerably older than their US counterparts. Earlier diagnosis, with the help of PSA screening, leading to radical prostatectomy may widen the advantage of surgery reported in the Swedish study.

It's possible, too, that the frequency of erectile dysfunction (ED) may be considerably higher in the Swedish study men after surgery than would be the case in the USA. Surgery in the Swedish study was not specifically aimed at preserving the nerves required for penile erection. In the USA, ED is usually reported in only 15% to 40% after appropriate nerve-sparing surgery.

It's also important to remember that another major option for prostate cancer -different types of irradiation - has not yet been evaluated in the same rigorous fashion as that used in the Swedish study. And some patients are treated by hormonal therapy, or undergo castration, following prostatectomy.

Consequences for the patient

In spite of the obvious benefits of radical prostatectomy found in this study, the procedure is not necessarily the best option for all early prostate cancers. Many patients are best treated by watchful waiting - for instance those that are too old or too ill to live more than 10 years, for any reason. Some men with only a slight increase in their PSA but with no tumor found on digital examination - about 10% to 20% - are also candidates for watchful waiting. And for those with larger tumors, or who are otherwise unwell, radiotherapy is probably the most appropriate treatment.

Studies that compare radical prostatectomy with irradiation are being started. Until the results are in, it's not possible to know just how good radiotherapy is, in comparison to other treatments. Nevertheless, nerve-sparing radical prostatectomy for early prostate cancer seems today to be an excellent choice for men under 65, if they are prepared to accept a slightly increased chance of impotence and urinary leakage. However, the final choice must rest with the patient, in full knowledge of all the available facts.

One of our readers sent us this feedback on the above article, and gave us permission to post it here. If you want to contact him, his e-mail address is ray_couch@hotmail.com . If you would like to contribute to this discussion, please use the box in the feedback form below. Robert Griffith MD, Content Editor.

I appreciate the opportunity to provide some input, regarding prostate cancer and watchful waiting. I am now 55 yrs. of age; I was 54 when I had a simple open prostatectomy, in Nov. of 2001, because of a grossly enlarged prostate gland. Then, a small focus of cancer cells was found in the examined tissue. I had been followed for years (due to BPH) and had NO symptoms other than an abnormally elevated PSA and difficulty urinating. I had gone through at least four biopsy procedures - all negative - as well as ultrasounds, etc. After the cancer was finally discovered, my urologist opted for watchful waiting. However, I wasn't satisfied and contacted a urology group in a nearby city. They researched my status and came to the conclusion that (primarily because of my age being 54) I should have a radical prostatectomy. They felt radiation wasn't an option, because the focus of cancer cells was so small the chance of it being missed was too great. So, in May of 2002, I had a radical prostatectomy. Between Nov. 2001 and now, I have been in and out of the hospital . . . .because of urinary infections and one-day surgeries to remove recurrent scar tissue. As a result of the radical prostatectomy this past May, I had two cardiac arrests but no heart damage from them. In fact, I had a very unremarkable heart catheterization. My present urologist is optimistic that all of the cancer is gone. My first and only PSA test, since the radical prostatectomy this past May, resulted in a score of 0.19... with the ideal test result being zero. To get back to the surgical consequences, I have ED and difficulty with controlling my urination. I feel that both of these consequences have improved, though. Even so, the aforementioned surgical consequences have caused me considerable psychological distress, for various reasons. One reason being that I got married for the first time in April of this year... about 5 wks. before my radical prostatectomy in May. I have wondered about my situation, but this article has put me somewhat at ease and has made me even more certain that watchful waiting probably wasn't a good option for me. Thank you for this opportunity to share my experience!