Most men who are diagnosed with prostate cancer can delay or avoid tough treatments without harming their chances of survival, according to new results from a long-term study in the United Kingdom.
Men in the study who partnered with their doctors to keep a close eye on their low- to intermediate-risk prostate tumors — a strategy called surveillance or active surveillance — reduced their risk of life-altering complications, such as incontinence and erectile dysfunction that can. followed aggressive treatment for the disease, but were no more likely to die of their cancers than men who had surgery to remove their prostate or who were treated with hormone blockers and radiation.
“The good news is that if you have been diagnosed with prostate cancer, do not panic, and take your time to make a decision” about how to proceed, said the study’s lead author Dr. Freddie Hamdy, professor of surgery and urology to the doctor. University of Oxford.
Other experts who did not participate in the research agreed that the study was reassuring for men who are diagnosed with prostate cancer and their doctors.
“When men are properly evaluated and their risk assessed, you can delay or avoid treatment without missing the opportunity to cure a large fraction of patients,” said Dr. Bruce Trock, professor of urology, epidemiology and oncology in the Johns Hopkins University.
The results do not apply to men who have prostate cancer that is scored by the tests to be high risk and high grade. These aggressive cancers, which account for about 15% of all prostate cancer diagnoses, still need prompt treatment, Hamdy said.
For others, however, the study adds to a growing body of evidence that shows that prostate cancer surveillance is often the right thing to do.
“What I take from this is the safety of doing active monitoring in patients,” said Dr. Samuel Haywood, a urologic oncologist at the Cleveland Clinic in Ohio, who reviewed the study but was not involved in the research.
The results of the study were presented on Saturday at the annual conference of the European Urology Association in Milan, Italy. Two studies on the data were also published in the New England Journal of Medicine and a companion journal, NEJM Evidence.
Prostate cancer is the second most common cancer in men in the United States, behind non-melanoma skin cancers. About 11% – or 1 in 9 – American men will be diagnosed with prostate cancer in their lifetime, and overall, about 2.5% – or 1 in 41 – will die from it, according to the National Cancer Institute. About $10 billion is spent on treating prostate cancer in the United States each year.
Most prostate cancers grow very slowly. It usually takes at least 10 years for a tumor confined to the prostate to cause significant symptoms.
The study, which has been going on for more than two decades, confirms what many doctors and researchers have understood in the meantime: the majority of prostate cancers are detected by blood tests that measure the levels of a protein called specific antigen of prostate, or PSA, do not harm men during their lifetime and do not require treatment.
Dr. Oliver Sartor, medical director of the Tulane Cancer Center, said that men need to understand that much has changed over time, and doctors have refined their approach to diagnosis since the study began in 1999. .
“I wanted to be clear that the way these patients are examined and biopsied and randomized is very, very different from how these same patients might be examined, biopsied and randomized today,” said Sartor, who wrote an editorial about the study, but it wasn’t. involved in research.
He says that the men included in the study were in the early stages of their cancer and were mostly at low risk.
Now, he says, doctors have more tools, including MRI imaging and genetic testing that can help guide treatment and minimize overdiagnosis.
The authors of the study say that to mitigate the concern that their results may not be relevant to people today, they reevaluated their patients using modern methods to classify prostate cancers. By these standards, about a third of their patients would have intermediate or high-risk diseases, something that did not change the conclusions.
When the study began in 1999, routine PSA screening for men was the norm. Many doctors encourage annual PSA testing for their male patients over 50.
PSA tests are sensitive but not specific. Cancer can raise PSA levels, but so can things like infections, sexual activity and even riding a bike. Elevated PSA tests require further evaluation, which may include imaging and biopsies to determine the cause. Most of the time, all that follow up just isn’t worth it.
“It is generally thought that only about 30% of individuals with an elevated PSA actually have cancer, and of those who do have cancer, the majority do not need treatment,” said Sartor.
Over the years, studies and modeling have shown that using regular PSA tests to screen for prostate cancer may do more harm than good.
According to some estimates, up to 84% of men with prostate cancer identified through routine screening will not benefit from having their cancers detected because their cancer would not be fatal before dying from other causes.
Other studies have estimated about 1 to 2 in every five men diagnosed with prostate cancer is overtreated. The harms of excessive treatment for prostate cancer are well documented and include incontinence, erectile dysfunction and loss of sexual power, as well as anxiety and depression.
In 2012, the influential US Preventive Services Task Force advised healthy men to not have PSA tests as part of their regular check-ups, saying that the harms of screening outweigh its benefits.
Now, the task force opts for one more individualized approach, saying that men between the ages of 55 and 69 should make the decision to undergo periodic PSA tests after carefully weighing the risks and benefits with their doctor. They recommend against PSA-based screening for men over 70.
The American Cancer Society strongly endorses it the same approachrecommending that men at average risk have a conversation with their doctor about the risks and benefits starting at 50 years.
The trial followed more than 1,600 men who were diagnosed with prostate cancer in the United Kingdom between 1999 and 2009. All men had cancers that had not metastasized, or spread to other parts of their body.
When they joined, the men were randomly assigned to one of three groups: active monitoring or using regular blood tests to monitor their PSA levels; radiotherapy, which used hormone-blockers and radiation to shrink tumors; and prostatectomy, or surgery to remove the prostate.
Men who were assigned monitoring could change groups during the study if their cancers progressed to the point where they needed more aggressive treatment.
Most of the men were followed for about 15 years, and for the most recent data analysis, the researchers were able to obtain follow-up information on 98% of the participants.
In 2020, 45 men – about 3% of the participants – had died of prostate cancer. There were no significant differences in prostate cancer deaths between the three groups.
Men in the active monitoring group were more likely to have their cancer progress and more likely to spread compared to the other groups. About 9% of men in the active monitoring group saw their cancer metastasize, compared with 5% in the two other groups.
Trock points out that even if it didn’t affect his overall survival, a cancer that spread is not an insignificant result. It can be painful and may require aggressive treatments to manage at this stage.
Active surveillance has had significant benefits over surgery or radiation.
As they followed the men for more than 12 years, the researchers found that 1 in 4 to 1 in 5 of those who had prostate surgery needed to wear at least one pad a day to protect against urine leakage. That rate was twice as high as the other groups, said Dr. Jenny Donovan of the University of Bristol, who led the study on patient-reported outcomes after treatment.
Sexual function was also affected. It is natural for sexual function to decline in men with age, so at the end of the study, almost all men reported low sexual function, but their patterns of decline were different depending on the treatment of the prostate cancer, he said.
“The men who have the surgery have low sexual function in the beginning, and this continues. The men in the radiation therapy group see their sexual function go down, then they have some recovery, but then their sexual function goes down, and the active monitoring group slowly declines over time,” Donovan said.
Donovan said that when he presents his data to doctors, it shows how much has changed since the study began.
“Some people say, ‘OK, yes, but we have all these new technologies now, new treatments,'” he said, such as intensity-modulated radiation therapy, brachytherapy and robot-assisted prostate surgery, “but actually, other studies have shown that the effects on these functional results are very similar to the effects that we see in our study,” he said.
Donovan and Hamby feel the study’s conclusions still deserve careful consideration by men and their doctors as they weigh treatment decisions.
“What we’re hoping clinicians will do is use these figures that we’ve produced in these papers and share them with men so that men recently diagnosed with localized prostate cancer can really evaluate those trade-offs,” Donovan said.