Over 200,000 men will be diagnosed with prostate cancer this year. The majority of these men (90%) will have localized disease. It has been established that early prostate cancer is over diagnosed and over treated. The dilemma for most of these men will be whether to treat or not to treat.
The Scandinavian Prostate Cancer Group Study has provided evidence that after a median follow-up of 12.8 years, patients treated with surgery (prostatectomy) had a greater survival than patients treated with watchful waiting by about 5% (87.5% vs. 82.1%). Metastasis was also less likely to be found in the treated group by 6% (19.3% treated vs. 26% not treated). This survival benefit was restricted to men younger than 65 years of age, Gleason score <7.
This survival benefit may not be relevant in men identified by PSA screening, as in the Scandinavian study 88% of patients had palpable tumors, implying a more advanced stage. In the US the median age at diagnosis of prostate cancer is 67, fewer than 50% have palpable tumors, and the lead time associated with prostate cancer detection from PSA screening has been estimated to be as long as 10 years. The only reason to question therapy is the price one has to pay in side effects and decrease quality of life issues. Prostatectomy is associated with erectile dysfunction and urinary incontinence.
Advancements in the delivery of radiation therapy, including image guided and focusing techniques, have allowed for improvements in the rates of disease control similar to surgery. Large, randomized studies comparing the two modalities in early stage disease are lacking. Radiation therapy is associated with bladder irritability, bowel symptoms and at some point erectile dysfunction as well. Adjuvant hormone therapy, shown to benefit patients receiving radiation therapy, increases the side effect profile with vitality and hormonal function issues.
Treatment-related symptoms are exacerbated by obesity, large prostate size, high PSA score, and older age. These changes influence satisfaction with treatment outcomes in patients and their partners. In the end, the decision to treat or not to treat is a personal one with one’s urologist acting as coach. The question to ask: “…is the promised benefit at the end of the road worth the price paid in decrease quality of life en route?”