Men diagnosed with prostate cancer can now choose from at least four treatment options: Watchful waiting, radical prostatectomy, external beam radiation, and implantation of radioactive "seeds" into the prostate (brachytherapy). But which treatment is best?
For men aged 65 or older with early-stage, moderate prostate cancer, the best approach may be watchful waiting — doing nothing other than repeated examinations and blood PSA tests.
In one major study of over 9,000 older men with low-grade (Gleason score 6 or less), early-stage cancers, only 5 percent died from their disease. Over 80 percent survived for 10 years without any complications, or died from causes unrelated to their cancers.
Watchful waiting, however, is not a good choice for older men with higher grade, early-stage prostate cancer, even if they have a relatively short life expectancy.
The answer is not as clear for younger men newly diagnosed with prostate cancer. One review article published online in The Annals of Internal Medicine analyzed the results of 18 randomized controlled trials and 473 observational studies.
But in the end, this review provided little help in deciding on the best treatment option for these younger men. One reason, according to the authors, is that serious limitations in the evidence made it difficult to compare treatments.
For example, only three of the 18 controlled trials directly compared the effectiveness of three treatments. Of these, one trial found that radical prostatectomy significantly reduced deaths from prostate cancer, whereas another smaller trial found no significant difference between radical prostatectomy and watchful waiting. None of the randomized trials evaluated brachytherapy.
The effectiveness of each treatment, as well as their respective complications, varied widely among the many observational studies, too. And it takes many years after therapy to determine the differences in the rates of cancer spread and survival from prostate cancer.
All of these treatments may lead to complications. The most frequent are impotence and urinary leakage (incontinence). And the studies conflict here, too. While incontinence was about as likely after either radical prostatectomy or external radiation, one large study (the Prostate Cancer Outcomes Study) found incontinence was significantly more common after radical prostatectomy than after external radiation. Impotence occurs frequently after all treatments, but is probably more common after radical prostatectomy.
Given the uncertainties regarding outcome, I advise most men with prostate cancer to consult both a urologist (more likely to recommend radical prostatectomy) and a radiation therapist (more likely to suggest some form of radiation treatment) before deciding on any particular treatment.
In the end, each man's decision must be based not only on the prostate cancer itself but also on the importance he places on the effectiveness of treatment, its convenience, and the likelihood of complications.
Some of my patients have chosen brachytherapy as the most convenient form of treatment. Others elected radical prostatectomy because they couldn't tolerate the notion of allowing a cancerous growth to remain in their bodies.
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