Watchful Waiting

Most men with localized prostate cancer can be safely watched rather than undergo treatment right away, the PIVOT study reported in the New England Journal of Medicine demonstrates.  Wow!  I quip to Rick in PodMed this week; does this mean the FINAL word on watchful waiting, a.k.a 'expectant management,' or even 'active surveillance' or just simply 'observation' is in?  As Rick so aptly points out, I may be feeling a bit tired of the topic because I lack a prostate gland, but even so, this controversy has raged long enough and a lot of evidence has accumulated.  So what about this latest study?

Researchers recruited 731 men, mean age 67 years, mean PSA 7.8 ng/ml, with localized prostate cancer, to either radical prostatectomy or observation, then followed them for a mean of 10 years.  Outcomes included all cause mortality and prostate cancer mortality.  With regard to prostate cancer mortality, 21 of the men assigned to radical prostatectomy died during follow-up, while 31 men assigned to observation died of their disease.  The researchers calculate the absolute risk reduction of dying from prostate cancer among those treated with radical prostatectomy as 2.6%.

What about all-cause mortality? During the follow-up period, 171 of the 364 men assigned to radical prostatectomy died, and 183 of 367 men assigned to observation did so.  Treatment therefore has little effect on either all-cause or prostate cancer specific mortality, and also did not seem to be impacted by race, age, co-existing medical conditions or histologic features of the tumor.  Well.  What then is the role of radical prostatectomy?

The authors state that in men with PSA values above 10 ng/ml, or those with intermediate or high-risk tumors, the operation may be indicated.  Hmmm, I say to Rick.  When we talk about ongoing controversy PSA as a reliable indicator of much remains a hot topic, as does Gleason score as a way of evaluating prostate tissue.  What factors should propel men into choosing surgery?

Many physicians, including Rick, say that each man's decision must take his own personal factors into account when making a decision to treat or watch.  Factors to consider include not just the PSA level and the Gleason score, but ethnicity, family history, comorbidities, remaining expected years of life, risk tolerance, and perhaps others. The risks of  treatment must also be weighed: in this study just over 21% of men who were treated with radical prostatectomy experienced an adverse outcome within 30 days of surgery, including one death.  Previous research has established that the prospect of urinary incontinence and sexual dysfunction dissuade many men from surgery, with especially poignant retrospective studies establishing their regret at choosing surgery when such outcomes were experienced.

Admittedly, it's easy for me to reach the conclusion that if I had localized prostate cancer I would elect active surveillance since that won't ever happen in my lifetime.  Reiterating 'active surveillance' is germane, though, since the clear goal is to keep checking it to make sure things are okay.  For now, I would say to almost any man who's looking at ads for robotic prostate surgery, caveat emptor.  Pay attention, consider very carefully, and perhaps just wait and see.

Other topics this week include egg allergy treatment in NEJM, the dangers of eating disorders in Pediatrics, and in Annals of Internal Medicine, reducing trans fats in fast food.  Until next week, y'all live well.

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Stephen Knows Cancer March 25, 2013 at 11:49 pm

I was wondering if you had any thoughts on the prostate drug known as Zytiga? I am pretty sure that this cancer drug was approved in 2011, but since then it seems to have been making some serious waves in the medical community. Zytiga is a unique compound which actually penetrates the cancerous cells. It seems that this is what makes it that much more effective than other drugs that have been approved by the FDA for cancer. In fact, I heard that the results in clinical testing were so impressive that the researchers decided to allow all participants access to Zytiga.

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Elizabeth Tracey March 29, 2013 at 10:11 am

sounds like you know a lot more about this than I do, so perhaps you'd like to state your references?

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