Radical Prostatectomy or Watchful Waiting in Early Prostate Cancer

   March 10, 2014   


A 23-year randomized study from New England Journal of Medicine looked at 695 men (mean age of 65) with early prostate cancer who proceed with watchful waiting or radical prostatectomy and followed them through the end of 2012. The patients included in the study had PSAs less than 50 and negative bone scans.
This is huge news that we’ve been waiting for almost two decades, until now watchful waiting was always ahead of surgery. It’s been popular because people want to hear that you don’t need surgery. You don’t have to have the risk of surgery. This research study will hopefully put an end to this debate and have people realize that surgery for prostate cancer under the age of 65 years is absolutely superior over watchful waiting.
If there were signs of local occurrence hormone therapy was initiated in the prostatectomy group (PSA or palpable nodule) and if metastatic disease was confirmed in the watchful waiting group. During the 23 years of follow up there was an overall reduction in death in the radical prostatectomy group.
By the end of 2012, 200 men in the radical prostatectomy group and 247 men in the watchful waiting group died, thus making the incidence of death at 18 years at 56.1% in the radical prostatectomy group and 68.9% in the watchful-waiting group.
It seems that people are critical of prostate surgery because it has debilitating effects over their lifetime. However, prostate cancer deaths (11 percentage point difference): deaths specifically due to prostate cancer were 63 in the radical prostatectomy group and 99 watchful waiting group (incidence of 17.7% and 28.7% respectively).

Metastatic Disease Progression(12.2 percentage point difference): The incidence of distant metastases was 26.1% in the radical prostatectomy group and 38.3% in the watchful-waiting group.

Hormone Therapy (24.9 percentage point difference): The use of androgen-deprivation was 42.5% in the radical prostatectomy group and 67.4% in the watchful waiting group.

Other Palliative Treatments: Radiation therapy in the radical prostatectomy was 49% versus 63% in the watchful-waiting group.  Also 4 men in the radical prostatectomy group underwent laminectomy due to metastases. There was also a decrease of chemotherapy in the radical prostatectomy group.

Age/Risk Analyses: Men that were younger than 65 and men with intermediate-risk tumors had the most significant differences. Also, men older than 65 years of age who underwent radical prostatectomy had a more significant decrease in risk of metastases and need for additional therapy. Older men showed an increased risk in death from causes other than prostate cancer.

Quality of Life: Metastases and the use of hormone therapy are strongly associated with a reduced quality of life. Measures to show quality of life were erectile dysfunction (ED) and urinary leakage. There was erectile dysfunction in of 84% in the radical prostatectomy group and 80% in the watchful waiting group (only a 4 percentage point difference). The bigger measure was in urinary leakage with shows 41% (surgery) and 11%, (watchful waiting)

With men living longer due to heart disease going down, oncologist are going to be faced with these statistics. So if we are going to be living longer, we need better quality surgeons to get the cancer out and no more watchful waiting.

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