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Prostate Cancer Treatments Can Be Avoided Or Delayed In Many Cases, Study Finds
When a man is diagnosed with prostate cancer, he has two choices to make. He may choose to be treated or to keep a watchful eye on the often slowly progressing disease. If he selects treatment, he then must decide on the type of treatment that seems most suitable.
New research presented this month at the European Association of Urology (EAU) Congress in Milan, Italy reports the results of a study comparing the outcomes associated with each of these choices. The study is the longest-running of its kind.
While the course of their disease varied somewhat depending on their decision, even men whose cancer had metastasized survived.
The study tracked 1,643 men in the United Kingdom aged 50–69 years who were diagnosed with prostate cancer between 1999 and 2009 based on the results of a PSA blood test.
As part of the study, participants agreed to be randomly assigned to actively monitor their disease, radical prostatectomy surgery, or radical radiation-based therapy.
The study appears in the New England Journal of Medicine.
The PSA or prostate-specific antigen blood test itself is somewhat controversial.
The study's lead author, Dr. Freddie Hamdy, explained that PSA tests "can be followed by a snowball of further testing, including biopsies of the prostate." If cancer is found, he said, it is likely localized and low risk.
"With this testing," Dr. Hamdy warned, a 'healthy' man can become a 'cancer patient' unnecessarily."
With this in mind, the U. S. Preventive Services Task Force on Prostate Cancer recommended about a decade ago that physicians stop including PSA screenings in checkup bloodwork. Since then, however, diagnoses of advanced prostate cancer detected by other means have significantly increased, and many physicians have resumed ordering PSA tests for their patients.
Prostate cancer most often — though not always — progresses slowly, taking many years to spread or metastasize beyond the prostate.
The three most common medical responses to a diagnosis of prostate cancer are:
Both radical prostatectomy and radical radiotherapy are frequently accompanied by lifestyle-altering adverse effects, such as erectile, urinary, and bowel dysfunction.
"Nowadays, it's not just radiation or surgery that are the options," noted Dr. Adam Ramin, who was not involved in the study.
"The advantage of that is that in many instances we can actually convert prostate cancer into a chronic disease, you know, just like diabetes or hypertension," Dr. Ramin said.
He noted that there are many men who may be good candidates for a treatment option called focal therapy. Focal therapy targets cancer through various means, including high intensity focused ultrasound, cryotherapy, laser ablation, and photodynamic therapy.
While the study found that men who opted for active monitoring were twice as likely to see it progress or metastasis, few of them died during the follow-up period.
Of the men who participated in active monitoring, cancer in 9.4% metastasized, compared to men who received a prostatectomy (4.7%) or radiation (5.0%).
For men whose cancer metastasizes, Dr. Ramin reported that while chemotherapies have not changed much over the years, there have been advances in hormonal manipulation-type therapies or androgen suppression therapies.
"Ten, 15 years ago, we only had one or two different kinds of hormone therapies," he said. "Now, there's a whole slew of them which work through different mechanisms."
Dr. Benjamin H. Kann, also not involved in the study, added:
"New systemic therapies helpful for the metastatic disease include (177)-lutetium-PSMA-617, a radiopharmaceutical that selectively attaches to a specific protein on prostate cancer cell surfaces and destroys the cell."
"The two most important factors are what we call the stage and the grade of the cancer, and how advanced the cancer is great means how aggressive the cancer is," said Dr. Ramin.
Dr. Ramin noted that molecular studies performed on biopsied tissue could provide better prognosis indicators in assessing whether a person is a suitable candidate for active monitoring or not.
One of the study's findings was that because of advances in diagnostic techniques, many of the men who were diagnosed as being at low risk of metastasis years ago would now be diagnosed at intermediate risk.
Dr. Hamdy told the EAU in a press release:
"It's clear that, unlike many other cancers, a diagnosis of prostate cancer should not be a cause for panic or rushed decision-making.
Patients and clinicians can and should take their time to weigh up the benefits and possible harms of different treatments in the knowledge that this will not adversely affect their survival."
Dr. Kann said another factor is the person's overall health and apparent life expectancy: "Men with shorter life expectancies due to age or other significant health issues may be more appropriate to monitor."
Beyond that, Dr. Hamdy told Medical News Today, the choice may depend on a man's "priorities in life, their other medical conditions (if any) and fitness, and measuring the 'trade-off' between treatment benefits and potential harms, particularly with sexual function, urinary leakage, and bowel symptoms."
15-Year Study Finds It's Safe To Delay Treatment For Low-Risk Prostate Cancer
Most men diagnosed with low-risk prostate cancer can safely delay radiation or surgery without increasing their risk of death due to the cancer, according to research presented at the European Association of Urology (EAU) Congress in Milan and published on March 11 in The New England Journal of Medicine.
The study results showed that although men on active monitoring were more likely to have their cancer advance or spread, they had the same high survival rates — 97 percent after 15 years — compared with men who had radiation or surgery.
"It's clear that, unlike many other cancers, a diagnosis of prostate cancer should not be a cause for panic or rushed decision making," said lead author Freddie Hamdy, MD, professor of urology and head of the Nuffield department of surgical sciences at the University of Oxford in England, in a press release.
"Patients and clinicians can and should take their time to weigh up the benefits and possible harms of different treatments, in the knowledge that this will not adversely affect their survival," said Dr. Hamdy.
"This is a landmark study that was well designed with a large number of patients and a 15-year follow-up," says Nitin Yerram, MD, co-director of urologic oncology and director of urologic research at Hackensack University Medical Center in New Jersey. "And it's telling us that surveillance is a really great option for men with low-risk prostate cancer, [since it] resulted in the same mortality rates as surgery and radiation," says Dr. Yerram, who was not involved in the study.
To Treat or Not to Treat? It's ComplicatedProstate cancer is the second leading cause of cancer death in American men behind lung cancer, according to the American Cancer Society. Although prostate cancer often grows slowly and is confined to the prostate gland, some types of prostate cancer can be aggressive and spread to other areas in the body, per Mayo Clinic.
There is evidence to support active surveillance and nontreatment of prostate cancer and, at the same time, there is evidence to suggest that some treatments for prostate cancer are important in prolonging survival, says Shawn Dason, MD, a urologic oncologist at The Ohio State University Comprehensive Cancer Center in Columbus.
"This is really the challenge for clinicians in today's world," says Dr. Dason, who was not involved in the study. "After assessing the risk level, we need to make sure we're not overtreating [patients] by potentially giving them treatments that could have urinary or sexual side effects. But in many cases, we will eventually need to treat with radiation and surgery."
Prostate Cancer Survival Rates Were the Same for Active Monitoring, Radiation, and SurgeryParticipants included a total of 1,643 men between 50 to 69 years old from across the United Kingdom who were diagnosed with localized prostate cancer after a PSA blood test between 1999 and 2009. All the men had cancers that had not metastasized or spread to other parts of their bodies, and 77 percent of the participants were considered low-risk at the start of the study.
Low-risk prostate cancer — also called localized prostate cancer because it's found only in the prostate — often grows very slowly or doesn't grow at all, according to InformedHealth.Org.
When they joined, the men were randomly assigned to one of three treatment groups:
Men in the active monitoring group were more likely to have their cancer progress and more likely to have it spread compared with the other groups. If the cancers progressed to the point that they needed more treatment, these men could change groups.
In addition to the 97 percent survival rate found in all groups, close to 1 in 4 men in the active monitoring had still not had any invasive treatment for their cancer after 15 years.
The high survival rate among the active surveillance group is also surprising because about 30 percent of the men in the study actually had intermediate-risk prostate cancer, which was only revealed after their original health data was reanalyzed later using modern tests that weren't available when the study began.
This is a seminal study in the field, says Dason, because there are very few studies of this size and this length of follow up. "These findings show that it's likely safe to monitor these patients until their cancer progresses and then treat them at the time of progression. It really supports active surveillance for a lot of these patients," he says.
"Patients and doctors now have the necessary information on the long-lasting side effects of treatments to better understand the trade-offs between their benefits and harms," said coauthor Jenny Donovan, PhD, professor at the University of Bristol in England, in a press release.
Since survival was the same for all three options, men diagnosed with localized prostate cancer can use their own values and priorities when making the difficult decisions about which treatment to choose, said Dr. Donovan.
Advancements in Imaging and Biopsies Make Surveillance Even More Effective"When somebody is diagnosed with low-risk prostate cancer and it's decided that you don't need to treat this right away, [doctors need to] very closely follow them to look for progression — that's called active surveillance," says Dason.
It's worth noting that active monitoring as it was performed in this trial has improved greatly in the past 15 years, according to an accompanying editorial in The New England Journal of Medicine. When this study started, researchers didn't have all the tools available today, such as safer biopsies and better imaging, including prostate MRI, notes Dason.
About 9 percent of men in the active monitoring group had their cancer metastasize, compared with 5 percent in the two other groups. Those numbers would likely be smaller if currently available monitoring tools were used, noted the editorial.
"Nowadays, active surveillance for prostate cancer could include PSA (prostate-specific antigen) testing every six months, MRI testing every two years, repeat biopsies, maybe up front at a year after diagnosis, and then every three to five years," says Dason.
Prostate Cancer Treatment May Affect Urinary and Sexual FunctionPatients from all three groups reported similar overall quality of life, in terms of their general mental and physical health, according to the findings.
Investigators found that the negative impacts of radiation and surgery on urinary and sexual function persist much longer than previously thought — up to 12 years in some cases.
There's no doubt that there are urinary and impotence issues following both radiation and surgery, says Yerram. "But as men get older, these issues can occur even without treatment for prostate cancer, and so it's hard to tease out the effects of the treatments," he says.
By the end of the study, nearly all the men reported low sexual function, but their patterns of decline were different depending on their prostate cancer treatment, said Donovan.
The Bottom Line: Surveillance Is a Safe Option for Many, but Not All, Men With Prostate CancerAlthough these findings support active surveillance, it's important not to put all people with prostate cancer in the same bucket, says Yerram. "We need to have individual discussions to see the best treatment plan for them," he says.
There are also more men being diagnosed with more advanced prostate cancer in the last few years, says Yerram. "These are men with high-risk prostate cancer — prostate cancer that we're concerned might have spread based on some of our testing. It would be a mistake to think that these results apply to this group, because that wasn't the type of patient who was studied here," he says.
Those patients will almost certainly benefit from treatment both to improve their quality of life and to extend their lifespan, says Yerram.
New Drug Combination Could Give Prostate Cancer Patients Months Of Extra Life And Revolutionise Treatment
A new drug combination could give prostate cancer patients months of extra life and revolutionise treatment.
The usual procedure when the disease has spread is to fight tumours with drugs that block testosterone.
In aggressive cases, however, this hormone therapy can cease to be effective.
According to The Mirror, scientists have added olaparib - a DNA repair enzyme blocker in cancer cells - to the testosterone stopper abiratone.
After a trial involving 800 men, the combination was found to prolong the life of stage 4 patients by an average of 7.4 months compared with abiratone on its own.
A new drug combination could give prostate cancer patients months of extra life and revolutionise treatment. [File image]
68-year-old Dave Kinsey, from Wigan, Lancashire, went to the Christie NHS Foundation Trust in Manchester to participate in the PROpel trial, which is funded by Merck and AstraZeneca.
When he was diagnosed in 2016 and given three to five years, a blood test found that the retired civil engineer's PSA level was 36 against a normal range of 4 or below.
Mr Kinsey continued taking the drug combination after the trial ended last October and his PSA level now less than 0.1. He has no signs of active cancer.
The usual procedure when the disease has spread is to fight tumours with drugs that block testosterone. [File image]
According to The Mirror, Mr Kinsley said: 'The cancer was in the lymph nodes, in the neck, chest and my groin. Then the bone scan I had when I was assessed for the trial showed cancer in my spine.
'Since then, there's been no progression.'
Meanwhile, the study also found that adding olaparib means chemotherapy might not be required.
The treatment will now be considered by the National Institute for Health and Care Excellence.
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