Most men with prostate cancer can avoid or delay harsh treatments, long-term study confirms

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The study's findings, published in the New England Journal of Medicine, suggest that many men with early-stage prostate cancer can safely choose to monitor the disease instead of immediately opting for surgery or radiation therapy.Harsh treatments for prostate cancer can be delayed or avoided without harming a man's chances of survival, according to new results from a long-running study in the United Kingdom.The study's findings, published in the New England Journal of Medicine, suggest that many men with early-stage prostate cancer can safely choose to monitor the disease instead of immediately opting for surgery or radiation therapy.

Men who partnered with their doctors to keep a close eye on their low- to intermediate-risk prostate tumors (a strategy called surveillance or active monitoring) slashed their risk of the life-altering complications such as incontinence and erectile dysfunction that can follow aggressive treatment for the disease, but they 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.

"If you're diagnosed with prostate cancer, don't panic," said lead study author Dr. Freddie Hamdy, professor of surgery and urology at the University of Oxford. "Take your time to make a decision about how to proceed."

The study was reassuring for men who are diagnosed with prostate cancer and their doctors, according to other experts who were not involved in the research.

"You can delay or avoid treatment without missing the chance to cure in a large fraction of patients," said Dr. Bruce Trock, a professor of urology, epidemiology and oncology at Johns Hopkins University.

"Our findings do not apply to the 15% of men who have high-risk and high-grade prostate cancers," Hamdy said. "These aggressive cancers still need prompt treatment."

The study adds to a growing body of evidence that surveillance of prostate cancers is often the right thing to do.

"I think the takeaway from this is that active surveillance is a safe option for 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 announced on Saturday at the European Association of Urology's annual conference in Milan, Italy. The data from the study was also published in two separate articles in the New England Journal of Medicine and NEJM Evidence.

and easy to treat

Cancer is a common disease that is often low-risk and easy to treat.

Prostate cancer is the second most common cancer in men in the United States, behind non-melanoma skin cancers. According to the National Cancer Institute, 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. About $10 billion is spent treating prostate cancer in the US each year.

It typically takes at least 10 years for a tumor confined to the prostate to cause significant symptoms. Most prostate cancers grow very slowly.

For more than two decades, a study has been running that confirms what many doctors and researchers have come to realize in the meantime: The majority of prostate cancers picked up by blood tests measuring levels of a protein called prostate-specific antigen, or PSA, will not harm men during their lifetimes and don't require treatment.

"Men should understand that a lot has changed over time and that doctors have refined their approach to diagnosis since the study began in 1999," said Dr. Oliver Sartor, medical director of the Tulane Cancer Center.

"It's important to note that the screening, biopsy, and randomization process is much different now than it was when these patients were originally treated," said Sartor, who wrote an editorial on the study but was not involved in the research.

"The men included in the study were in the earliest stages of their cancer and were mostly low-risk," he says.

Now, he says, doctors have more tools, including MRI imaging and genetic tests that can help guide treatment and minimize overdiagnosis. He says that in the past, doctors didn't have access to as many tools and that overdiagnosis was more common.

The study authors say that to quell concerns that their results might not be relevant to people today, they re-evaluated their patients using modern methods for grading prostate cancers. By those standards, about one-third of their patients would have intermediate or high-risk disease, something that didn't change the conclusions.

It is often thought that the more treatment a patient receives, the better off they are. However, this is not always the case. In some instances, less treatment can actually be better care.One example of this is with cancer patients. It is sometimes better to provide them with fewer rounds of chemotherapy. This is because too much chemotherapy can actually do more harm than good. It can weaken the immune system and make it difficult for the body to recover.So, in some cases, less treatment can actually be better care. This is something that should be considered when making decisions about a patient's care plan.

In 1999, when the study began, doctors encouraged annual PSA tests for their male patients over the age of 50. This was routine at the time and many men had PSA screenings done on a yearly basis.

PSA tests are not very accurate. Cancer can raise PSA levels, but so can things like infections, sexual activity and even riding a bicycle. Elevated PSA tests require more evaluation, which can include imaging and biopsies to determine the cause. Most of the time, all that followup just isn't worth it.

'Approximately 70% of individuals with an elevated PSA will not have cancer, and of those that do have cancer, the majority will not need treatment,' Sartor said.

Studies and modeling over the years have shown that using regular PSA tests to screen for prostate cancer can do more harm than good.

Approximately 84% of men who have prostate cancer detected through routine screening may not benefit from the detection, as the cancer may not be fatal before the individual dies of other causes.

It is estimated that 1 to 2 out of every 5 men diagnosed with prostate cancer are overtreated. The harms of overtreatment for prostate cancer are well-documented and include incontinence, erectile dysfunction and loss of sexual potency, as well as anxiety and depression.

In 2012, the influential US Preventive Services Task Force advised healthy men not to get PSA tests as part of their regular checkups. The Task Force said the harms of screening outweighed its benefits.

Now, the task force recommends a more individualized approach, saying men between the ages of 55 and 69 should make the decision to undergo periodic PSA testing after carefully weighing the risks and benefits with their doctor. They recommend against PSA-based screening for men over the age of 70.

At age 50, the American Cancer Society recommends that men at average risk have a conversation with their doctor about the risks and benefits of cancer.

There was no impact on survival from the treatment.

More than 1,600 men who were diagnosed with prostate cancer in the UK between 1999 and 2009 are being followed in a trial. All the men have cancers that have not metastasized, or spread to other parts of their bodies.

When they joined, the men were randomly assigned to one of three groups: active monitoring, radiotherapy, or prostatectomy. Active monitoring involved using regular blood tests to keep an eye on PSA levels. Radiotherapy used hormone-blockers and radiation to shrink tumors. Prostatectomy involved surgery to remove the prostate.

If their cancers progressed to the point that they needed more aggressive treatment, men who were assigned monitoring could change groups during the study.

Now researchers have follow-up information on 98% of the participants, most of whom have been followed for around 15 years.

By 2020, 45 out of 1,500 men (about 3% of the participants) had died of prostate cancer. There were no significant differences in prostate cancer deaths between the three groups.

Compared with the other groups, men in the active monitoring group were more likely to have their cancer progress and spread. About 9% of men in the active monitoring group saw their cancer metastasize, compared with 5% in the two other groups.

"Even though it didn't affect their overall survival, a spreading cancer isn't an insignificant outcome," Trock points out. "It can be painful and may require aggressive treatments to manage at that stage."

Active surveillance had important benefits over surgery or radiation.

The researchers found that, of those who had prostate surgery, 1 in 4 to 1 in 5 needed to wear at least one pad a day to guard against urine leaks. This 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 declined in all the men, but the patterns of decline were different depending on their prostate cancer treatment," she said.

"According to Donovan, the men who have surgery experience low sexual function early on, and this continues. The men in the radiotherapy group see their sexual function drop, then have some recovery, but then their sexual function declines. The active monitoring group declines slowly over time."

"When I present my data to doctors, they always point out how much has changed since the study started," said Donovan.

Some people would say that new technologies and treatments, such as intensity-modulated radiation therapy, brachytherapy and robot-assisted prostate surgeries, have made no difference in functional outcomes. However, according to a study, the effects are actually very similar.

The study's conclusions still merit careful consideration by both Donovan and Hamby as they weigh treatment decisions.

"What we hope is that clinicians will use the figures from our papers to help men who have been newly diagnosed with localized prostate cancer understand the tradeoffs," Donovan said.