GREG'S LEGACY

Specialising in the human experience of Living with prostate cancer – warts and all

(RP) Surgery and mortality

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Physicians can now confidently recommend observation as the preferred treatment approach for most of their patients.

Our study showed (access requires registration) that men with early-stage prostate cancer treated with observation had similar length of life and deaths from prostate cancer,” Dr. Wilt told Medscape Medical News. “Physicians can now confidently recommend observation as the preferred treatment approach for most of their patients diagnosed with [early] prostate cancer.”

Notably, the Prostate Cancer Intervention Versus Observation Trial (PIVOT) also indicated that surgery provided no mortality benefit at all in men with early-stage (localized) disease that was low risk. Instead, observation appeared superior in low-risk men; it was associated with a nonsignificant reduction in both mortality measures.

Observation is a “wise, healthy choice for the large majority of men diagnosed with prostate cancer in the United States,” said Dr. Wilt, explaining that the harms related to treatment can be avoided, and that in PIVOT, (access requires registration) the risk for death from prostate cancer in the observation group was “low.”

The ultimate challenge moving forward in the management of prostate cancer is in accurately differentiating risk so that treatment can focus on men with “lethal cancer,” say the editorialists. “Prostate cancer is not a monolithic cancer but a spectrum of disease,” Dr. Thompson and Dr. Tangen write. Future clinical trials must focus on “cancers that matter,” they add.

there are at least two core pieces of information that come out of this trial to confirm the findings of others:

  • For men with low-risk, early stage, localized prostate cancer who are > 65 years of age and have a life expectancy of not more than 15 years, observation (i.e., active monitoring) is now shown to be every bit as effective as (and a great deal safer than) radical prostatectomy.
  • For men with low-risk, early stage, localized prostate cancer who are > 65 years of age and have a life expectancy of more than 15 years, it is arguable that observation (i.e., active monitoring) may be at least as good an option as radical prostatectomy (RP). (source)
  • Average (mean) age of the patients at enrollment was 67 years.
  • Average (median) PSA level of the patients at enrollment was 7.8 ng/ml.
  • Average (median) follow-up was 10.0 years.
  • During the follow-up period
    • 171/364 patients (47.0 percent) randomized to RP died.
    • 183/367 patients (49.9 percent) randomized to observation also died.
    • The absolute reduction in risk of death as a consequence of RP as opposed to observation was 2.9 percent (hazard ratio [HR] = 0.88).
    • 21/364 patients (5.8 percent) randomized to RP died either from their prostate cancer or as a direct consequence of their treatment.
    • 31/367 patients (8.4 percent) randomized to observation died from prostate cancer.
    • The absolute reduction in risk of death as a consequence of RP as opposed to observation was 2.6 percent (HR = 0.63).
  • Adverse events after surgery occurred within 30 days in 21.4 percent of patients treated by RP, inclusive of one death.
  • Among men with a baseline PSA > 10 ng/ml, RP was associated with a statistically significant  reduction in risk for all-cause mortality.
  • Among men with intermediate-risk or high-risk prostate cancer there appears to have been the possibility of a statistically signifciant reduction in risk for all-cause mortality.
  • There was no impact of treatment on all-cause and prostate-cancer mortality according to age, race, coexisting conditions, self-reported performance status, or histologic features of the tumor.

The authors conclude with the careful statement that:

Among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality, as compared with observation, through at least 12 years of follow-up.

So, don’t go there

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Written by Greg Naylor

3 August 2012 at 12:00 pm

One Response

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  1. Interesting but confusing…
    When it is based on ten years of subsequent observation, and we all hope for much more, then you have to wonder where our choices would go.
    The real question I have, is how come SOoo many men that I know have had an RP, suffer the issues of ED etc, and live full lives… 50% just does not seem consistent.. Does peace of mind not come into the occasion..?

    Peter

    3 August 2012 at 1:25 pm


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