The Prostate Dilemma In Treating Cancer
16 May 2005
What should I do? I’ve been diagnosed with cancer of the prostate gland and my doctor has suggested a radical prostatectomy. He claims that a new report shows that surgery is the best way to ensure a cure. Of all the letters I receive this question is always the hardest one to answer.
The New England Journal of Medicine recently published a study from Sweden in which doctors followed men with an average age of 65 years with prostate cancer for 10 years.
695 men with prostate cancer were treated with radical surgery. In radical prostatectomy surgeons remove the prostate, as well as surrounding tissue and lymph nodes. Another group of 347 men with the same problem were treated by watchful waiting.
At the end of 10 years 83 men (8.6 percent) in the surgical group had died compared to 106 men (14.4 percent) in the watchful waiting group. But the benefits of radical surgery appeared to be among men under 65 years of age.
Dr Anna-Bill Axelson of University Hospital in Uppsala, Sweden said that urologists who favour surgery over watchful waiting will now be able to tell their younger patients, "there is finally proof it saves lives."
But many readers might wonder, "Why in the name of heaven would you use watchful waiting to treat cancer. Haven’t we been told for years that early diagnosis and treatment is the only way to cure cancer? " But prostate cancer is a somewhat unique malignancy. It’s often so slow growing that many patients die of other diseases long before the cancer kills them.
As one of the world’s authorities on the treatment of prostate cancer reminded doctors years ago that, "growing older is invariably fatal, cancer of the prostate only sometimes." It’s unfortunately the "sometimes" that makes it hard to know what to advise patients. There is no 100 percent way of determining who falls into that category and who will or will not die from it.
So where does this new study leave men who are trying to make a rational decision about treatment?
Dr. Durado Brooks, director of prostate cancer at the American Cancer Society, says that in the Swedish study men were most often diagnosed when the tumour could be felt on rectal examination. This means it’s not an early cancer.
In this country many prostate cancers are more often diagnosed at an earlier stage by the use of the PSA test. So it’s hard to speculate what would be the results of radical surgery here compared to watchful waiting over a 10 year period.
So we are still left with needing the wisdom of Solomon to guide patients to the best treatment. Currently doctors have to consider the patient’s overall health, whether it’s an early or more advanced malignancy, a microscopic study of biopsies to see if it’s an aggressive tumour and the patients age.
In talking to many urologists the general opinion is that in younger men radical surgery offers the greatest chance of survival. But in those over 70 watchful waiting or other forms of treatment such as radiation makes more sense.
The great dilemma in deciding on surgery is the possibility of impotence and urinary incontinence. Fortunately, due to new surgical techniques that help to save important nerves, the chance of these complications has decreased. But if these problems occur at a young age they are not minor problems.
