Two important papers have recently been published in the New England Journal of Medicine regarding the management of prostate cancer. There has crept into the literature and the practice of urology an increasingly strong belief that watchful waiting for men recently diagnosed and who have a good prognosis is equivalent to surgery or radiation. From England, Hamdy and colleagues reported on a large trial in which men were randomly offered surgery radiation or close observation. After 10 years of follow up there was a big difference in death from prostate cancer, with men who opted for observation (which can include delayed treatment) doing worse. There was almost double the death rate in the observation group, although the absolute number of deaths was small — 17 vs. 5 (surgery) and 4(radiation) — with about 500 men in each group. Click here to download the abstract; Dr. Stark can send you the full article (see box on R). Given the very small death rate one has to question whether it is worth going through all that treatment. The authors seem to think so, but in all fairness men should make this decision for themselves. This paper is an important contribution because it emphasizes that watchful waiting is not entirely benign as a strategy.
The second paper looked at men who were not cured by initial radical prostatectomy and was written by William Shipley, a highly regarded radiation oncologist from Massachusetts General Hospital. Click here for the abstract. In this paper men whose PSA’s did not fall to zero following prostatectomy were all treated with radiation. Half of them received an anti-androgen as well to block at least partially the stimulatory effects of any remaining endogenous male hormone. At the end of twelve years there was a slight advantage in favor of the men who received the anti-androgen, but because the study was so large that difference achieved statistical significance (76 vs. 71% survival). The study was contaminated by the fact that all men whose disease progressed were placed on total androgen blockade — much more potent than just the anti-androgen. Not explicitly stated by the authors but true: radiation after failed radical prostatectomy will cure a substantial percentage of such men even without anti-androgens. Not also explicitly stated were the side effects of prolonged anti-androgens: osteoporosis, loss of muscle mass and psychiatric depression.