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Wait-and-see may be best for early prostate cancer

By Genevra Pittman

NEW YORK (Reuters Health) - Watching and routinely examining men with early, slow-growing prostate cancer is more effective and cheaper than sending them to surgery or radiation right away, according to a new study.

The findings are based on a model of 65- to 75-year-old men that takes into account costs of tests, treatment and missed work, treatment side effects, men's quality of life and their chance of dying from prostate cancer.

"Most of the men who are diagnosed in this country these days have low-risk prostate cancer," said Dr. Julia Hayes, who led the new study at the Dana-Farber Cancer Institute Boston.

That type of disease may never grow large or fast enough to threaten a man's life. But treating it can cause side effects such as incontinence and impotence.

"There's a huge group of men out there who are probably treated unnecessarily," Hayes told Reuters Health.

The American Cancer Society estimates about one in six U.S. men will be diagnosed with prostate cancer during his lifetime, and one in 36 will die of the disease.

Hayes and her colleagues compared the effects of immediate treatment after a diagnosis of low-risk cancer to one of two wait-and-see approaches.

With active surveillance, men had a prostate specific antigen (PSA) test every three months, as well as regular prostate biopsies and digital rectal exams. Watchful waiting involved a less intensive follow up, with PSA tests every six months and a bone scan every five years.

Among hypothetical 65-year-old men, 78 percent under active surveillance would ultimately undergo prostate cancer treatment, compared to 34 percent of those who went the watchful waiting route, Hayes and her colleagues found.

Because of that - and the fewer tests and biopsies along the way - watchful waiting turned out to be the cheapest approach. It also didn't leave men any worse off than other treatment strategies, the researchers wrote Monday in the Annals of Internal Medicine.

Their model showed that men's risk of ultimately dying from prostate cancer itself was 4.8 percent for those treated with active surveillance, 6.0 percent for watchful waiters and 8.9 percent among men who went straight to treatment. Men in all three scenarios had a life expectancy between 81 and 82 years.

Watchful waiting and active surveillance were both tied to improved quality of life, with a slight edge going to the less intensive monitoring, depending on what data was put into the model.

"It's yet another piece of the puzzle that observation in either form is beneficial," Hayes said.

Still, she said the model only spits out averages - and men still have to make the best decision for their own situation.

"This is an important study that adds to mounting evidence about the value of observation (watchful waiting) as a treatment option for many men, in particular for men with localized, low-risk prostate cancer," said Dr. Timothy Wilt, from the Minneapolis VA Health Care System and the University of Minnesota School of Medicine, whose data contributed to the model.

"It appears that … observation can help men live a similar length of life, prevent death from prostate cancer and avoid the harms associated with early treatment," Wilt, who wasn't involved in the new research, told Reuters Health.

Combined with the better quality of life and lower cost seen with watchful waiting, "That's a really winning combination for men," he said.

Wilt said he believes the model findings also apply to men in their late 50s and early 60s.

"The vast majority of the data suggests that observation is superior to early intervention with surgery or radiation and that it's even superior to active surveillance," Wilt added. "It allowed people to live longer, live better and less expensively."

SOURCE: http://bit.ly/PShmuj Annals of Internal Medicine, online June 17, 2013.

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