No one treatment is best for all patients with prostate cancer, and combining therapies may increase risk for adverse events but not improve prognosis, according to a U.S. scientific review published online February 4 by the Annals of Internal Medicine.

For instance, patients who undergo complete prostate removal are less likely to experience urinary incontinence or other complications if the surgery is done by an experienced surgeon in a hospital that does many of the procedures, according to the report funded by the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services.

"This report is a reminder that patient outcomes may vary according to treatment settings," said Director Carolyn M. Clancy, MD. "But this analysis also underscores a broader message: when it comes to prostate cancer, we have much to learn about which treatments work best, and patients should be informed about the benefits and harms of treatment options."

Treatment choices often take into account a patient's age, race, ethnicity, health status, family history, patient preferences and factors predictive of the tumor's biological behavior. The new report, based on a review of 592 published articles, compared eight prostate cancer strategies: complete surgical removal of prostate and related tissue; minimally invasive surgery to remove the prostate; external radiation; brachytherapy; cryotherapy; androgen deprivation therapy; high-intensity ultrasound; and watchful waiting.

One fundamental conclusion was that there is not enough scientific evidence to identify any prostate cancer treatment as most effective for all men, especially those whose cancers were found by prostate-specific antigen testing. Interestingly, more than 90 percent of patients reported they would make the same treatment decision again, regardless of the treatment they received.

All treatment options cause health problems, primarily urinary incontinence, bowel problems and erectile dysfunction. The chances of bowel problems or sexual dysfunction are similar for surgery and external radiation. Leaking of urine is at least six times more likely among patients treated with surgery than those treated by external radiation.

One study showed that men who choose surgery over watchful waiting are less likely to die or develop metastatic disease. The benefit appears to be limited to men under 65 years. However, because few patients in this study had cancer detected through blood screening, it is unknown if this finding would apply to those whose cancers were detected through such screening. Another smaller study showed no difference in survival between surgery and watchful waiting.

Among patients who choose surgery, urinary complications and incontinence are less likely if their surgeons performed more than 40 prostate removals per year. Surgery-related deaths, urinary complications and readmissions were lower and hospital stays were shorter in hospitals that performed more prostate removals.

A lack of research makes it impossible to compare several treatments: cryotherapy, minimally invasive surgery (laparoscopic or robotic assisted radical prostatectomy), androgen deprivation therapy, and high-intensity ultrasound or radiation therapy.

The addition of hormone therapy prior to prostate removal does not improve survival or decrease recurrence rates, but it does increase the chance of adverse events.

Combining radiation with hormone therapy may decrease mortality. However, compared with radiation treatment alone, the combination increases the chances of impotence and abnormal breast development.