28 July 1998

Prostate Cancer Treatment Seen in New Light

A new report from the Medical Journal of Australia sheds much needed clarity on some of the difficult decisions which need to be made in the treatment of prostate cancer.

Data which have become available in the last 2 years allows meaningful comparison of the three management options for prostate cancers have been detected early: namely

  1. 'watchful waiting' (institution of non-curative but remission-inducing androgen ablative treatment by hormonal therapy or orchidectomy [castration] on evidence of progression of the tumour);
  2. radiotherapy;
  3. radical surgery.

Although not yet conclusive, the accumulating evidence is suggesting that men with a life expectancy of more than ten years who have aggressive-looking tumours on histological criteria (a small piece of the tumour looked at through the microscope), do derive a significant survival advantage when treated more actively.

For example a study published in the Lancet last year reported that for early poorly differentiated tumour types at 10 years from diagnosis, 55% of men managed by watchful waiting will have died of this disease, compared to 'only' 33% treated with surgery. (Implying that 22 of each 100 men treated by surgery and alive after 10 years owe their survival to that surgery.)

There is also now some evidence of what the consumers think, with follow-up questionnaires of men suffering post-operative potency and incontinence problems indicating that they would, in most cases, given their time again, again choose to have surgery, in appreciation of the chance of improved disease-free and total life expectancy.

On the other hand older men (less than 10 year life expectancy) with well- differentiated cancer types can probably be managed by the 'watchful waiting' option without a decline (compared to surgery or radiotherapy) in disease-free and absolute survival figures: and thus be spared the trauma, and the adverse consequences, of these attempted curative interventions.

These data underline the obligations of the doctor to the patient in pre-test counselling and informed consent.

If, in the event that an individual is found to have an elevated PSA level (prostate-specific antigen -used to determine latent prostatic cancer), he is prepared to have multiple further uncomfortable investigations to establish the extent and type of disease; and then, if it is an aggressive-looking tumour, he would want to have invasive surgery or radiotherapy, with a risk of side-effects, in order to achieve a (probably statistically moderate but real) survival advantage: he should definitely go ahead and have the PSA test.

If, on the other hand, he is likely to decide against the active cure-directed treatments, and opt for the watchful waiting approach, there is a more questionable basis for embarking on testing: since we now have a man bearing bad news about his health, but with little evidence that this knowledge and the intended medical action (regular rectal examination, further PSA testing, and hormonal intervention) will actually improve his outcome.

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