More than half of the men with lower-risk prostate cancer who are good candidates for watchful waiting or active surveillance without therapy receive surgical or radiation therapy, according to an article in the August 16 issue of the Journal of the National Cancer Institute.

Research has shown that older men with lower-risk prostate cancer who choose watchful waiting are likely to die from another cause during the first 20 years after their cancer diagnosis. Meanwhile, surgery or radiation to treat prostate cancer can lead to complications such as erectile dysfunction, urinary incontinence and bowel difficulties.

“Just as a failure to treat a potentially lethal prostate cancer is generally considered inappropriate from a quality-of-care perspective, over-treatment of lower-risk cancers is also not in the patient’s best interest. For some men with early stage prostate cancer, surgery or radiation therapy may result in substantial negative effects without a survival benefit,” said co-author John T. Wei, MD.

The American researchers looked at 64,112 men diagnosed with early-stage prostate cancer using the Surveillance, Epidemiology and End Results registry, a population-based cancer registry maintained by the National Cancer Institute.

Men were divided into high-risk or low-risk categories based on tumor characteristics. Among the 24,835 men with lower-risk cancers, 55 percent were treated with initial surgery or radiation, suggesting that aggressive treatment is quite common even among men where an expectant approach is a viable option.
Among men with lower-risk cancers, those under age 55 years are more likely to be treated with surgery than watchful waiting. In contrast, men aged 70-74 years were more likely to be treated with radiation than watchful waiting.

From 2000 through 2002, more than 13,000 men with lower-risk cancer received treatment with surgery or radiation within the first several months after diagnosis. In this group, patients older than 70 years with mid-grade tumors were most likely to receive potentially unnecessary surgery or radiation within the first year after diagnosis.

“There are many men with prostate cancer who will benefit from early treatment with surgery or radiation therapy. However, prostate cancer is not a one-size-fits-all condition and we now know that many men are diagnosed with slowly growing cancers that are unlikely to cause symptoms or be fatal. Given that the average patient often has bothersome side effects of surgery or radiation, it is important to evaluate the barriers to greater use of expectant management approaches including active surveillance, particularly among this reasonably large group of men with lower-risk cancers,” said lead study author David C Miller, MD, MPH.

“Based on data from this study, it is clear that the number of lower-risk patients who receive initial aggressive therapy is not trivial and we have to ask the question whether this is too much treatment for some of these men,” Miller added. “We should continue to explore our patients’ preferences regarding the different treatments for early-stage prostate cancer and better educate them about the entire spectrum of options, including the appropriateness of initial active surveillance in many lower-risk cases.”

The authors report that for many men with lower-risk cancers a potentially appealing treatment option is called active surveillance. Building on the traditional concept of watchful waiting, active surveillance involves frequent monitoring of the tumor without immediate active treatment. Active surveillance can help distinguish between more-aggressive and less-aggressive cancers thereby improving doctors’ ability to identify the patients most likely to benefit from surgery or radiation.