For some men with prostate cancer, the best treatment is no treatment, study finds

Last year, about 192,000 American men were diagnosed with prostate cancer. For 16% to 40% of them, the disease is deemed to be so low-risk that no immediate medical intervention is necessary. Instead, they can undergo “active surveillance,” which means regular PSA tests, physical exams, and periodic biopsies to monitor the cancer’s growth. Treatments, including surgery to remove the prostate and different types of radiation, can be put off until the cancer gets bigger – if it ever does. Most treatments result in at least one adverse effect (such as erectile dysfunction and urinary incontinence). However, only about 10% men who have the option of delaying treatment opt for active surveillance.

A new study suggests that too many men are passing up a good thing.

Researchers from the Dana Farber Cancer Institute in Boston and elsewhere examined the pros and cons of active surveillance in a hypothetical group of 65-year-old men who just found out they have localized, low-risk prostate cancers. Using data from other studies, they assumed that those who opted for immediate treatment reduced their risk of dying from prostate cancer by 17%.

But when they factored in the side effects from treatment, those patients weren’t necessarily better off. Using a measure called quality-adjusted life years, or QALYs, they found that patients who opted for radiation treatment – either external beam radiation or brachytherapy – had slightly more than 10.5 QALYs. Those who had surgery had 10.2 QALYs, which works out to four fewer months in the “preferred health state.”

In contrast, patients who went with active surveillance spent an additional 6 months in the “preferred health state.”

But that doesn’t mean active surveillance is better for everyone. Though studies have shown that men are equally anxious whether they choose to watch and wait or get their treatment over with, the researchers found that active surveillance was better only for men who put a premium on maximizing their quality – not their quantity – of life.

The findings will be published in Wednesday’s edition of the Journal of the American Medical Assn.

“The message is clear: active surveillance was associated with the highest benefit in terms of quality adjusted life expectancy (by at least 6 additional months) compared with other treatment options,” according to an editorial that accompanies the study. However, the authors recognize that “for some men and their families, the concept that a cancer of any sort is not treated when found early is unthinkable.”

They continue:

“This sense of impending catastrophe is clearly unwarranted in the case of favorable-risk prostate cancer, given the high prevalence and low mortality associated with these tumors, and anxiety associated with the cancer diagnosis may be amenable to accurate information and reassurance. Indeed, one proposal suggests that small, low-grade prostate cancers should be referred to without including the term cancer, such as by referring to them as indolent lesions of epithelial origin.”

Perhaps a change in nomenclature would indeed encourage more men to choose active surveillance. As usual, more research is needed.

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