Treatment Beats Watchful Waiting for Older Prostate Cancer Patients

    Aggressive treatment of early prostate cancer, and not watchful waiting,
    improves the survival of older men, a new study
    suggests.

    “There has been a
    belief that watchful waiting was the safest treatment for older men with
    moderate prostate cancer,” said Dr. Yu-Ning Wong, an oncologist at Fox Chase
    Cancer Center who is lead author of the report in the Dec. 13 issue of the
    Journal of the American Medical Association. “Our study suggests there
    may be a survival benefit,” Wong said.

    But a more
    definitive answer will have to wait for the outcome of controlled studies that
    are under way, Wong added.

    “Our study was
    observational,” she said. “We looked at the records of men treated or not
    treated for prostate cancer. It was not a randomized, controlled
    trial.”

    The issue of
    treatment vs. watchful waiting has grown in importance as more men live longer;
    many are diagnosed with low- and intermediate-grade cancer that poses no
    immediate threat to their lives.

    The study looked at
    data on more than 44,000 such men, aged 65 to 80, who survived a year or more
    past diagnosis. About three quarters of them — 32,000 — had surgery or
    radiation therapy in the six months following diagnosis. Another 12,600 did not,
    as the physicians opted for watchful waiting.

    The death rate for
    men who received treatment was 31 percent lower over a 12-year follow-up period,
    the researchers reported. The death rate was 23.8 percent for those who had
    treatment, compared to 37 percent for those who did not.

    The reduced death
    rate was seen in all subgroups, including men aged 75 to 80 at diagnosis and
    those with low-risk disease.

    “The cautionary note
    when interpreting this trial is that although it suggests that every man should
    be treated radically, the decision must be made case by case,” said Dr. Mark S.
    Litwin, a professor of urology and public health at the University of
    California, Los Angeles, and co-author of an accompanying
    editorial.

    As a general
    principle, “we know that most men don’t die from it [prostate cancer], but die
    with it,” Litwin said. “One has to be careful to be sure not to over-treat. The
    treatment can be worse than the disease.”

    When making a
    decision, the doctor “has to be very astute in assessing a patient’s general
    functional status and overall health,” Litwin said. And the patient’s voice must
    be heard, he added.

    “The patient should
    be the driving voice,” Litwin said. “The physician must be cautious not to be
    paternalistic because this generally is not an acute, life-threatening
    illness.”

    Some smaller studies
    have indicated a benefit for watchful waiting, but most have found better
    survival with treatment, Wong said.

    “Ultimately, a
    randomized, controlled trial will give us the answer we are looking for,” Litwin
    said.

    Such a trial is
    being done by the U.S. Veterans Administration, Wong said. Results are expected
    in a few years.

    Until then, “the decision needs to be based on the patient’s overall
    condition and personal beliefs,” she said.

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