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Prostate Cancer Symptoms

Last month's newsletter reported a survey showing major deficiencies in patient education materials about prostate cancer. In covering this survey, our article mentioned a long-term Swedish study noteworthy for the fact that all the participants had early prostate cancer that remained untreated unless they experienced symptoms (watchful waiting). Coincidentally, that Swedish study published 21-year follow-up results right after our last newsletter went to press.

Here's what it found: 223 men with prostate cancer participated in this study; only 35 died of prostate cancer within the 21-year study period; 23 are still alive; and the rest died of other causes. Most were in their 60s and 70s when they were first diagnosed.

The study, headed by Jan-Erik Johansson, MD, of Orebro University Hospital in Sweden, is one of the longest follow-ups of untreated men. Its results have been published periodically in the Journal of the American Medical Association, most recently in the June 9, 2004 issue. 25 of the 35 men who died of prostate cancer did so within the first 15 years of the study.

The latest findings from the Swedish study make it hard to justify the immediate treatment upon diagnosis of all symptomless elderly men. In fact, the results make it hard to defend the current practice of recommending the prostate specific antigen (PSA) screening blood test to elderly men, given the overwhelming odds that they are more likely to die of something other than prostate cancer. Of the 28 Swedish men who were over the age of 80 years at diagnosis, 27 died of other causes. On the other hand, men diagnosed in their 60s or younger might opt for immediate treatment, according to the Swedish investigators.

Still No Accurate Test

Quite apart from age, the decision to treat or not to treat early-stage prostate cancer is made difficult by the fact that no test can accurately distinguish the small number of prostate cancers that will become rapidly fatal. This study, however, provides a hint in that direction. It confirmed earlier research showing that men with grade 3 tumors (poorly differentiated cells) are more likely to die of prostate cancer.

Quality-of-Life Considerations

Dr. Johansson and colleagues raised an interesting point about immediate treatment vs. treatment only if symptoms appear, stating that prolonged survival is not the only consideration. Quality of life is also an important issue. A radical prostatectomy (surgical removal of the prostate) was the usual immediate treatment in the era when the Swedish study began. And it remains the most common treatment today. But the treatments that await the men whose disease progresses are estrogen therapy or surgical removal of the testicles (orchidectomy). Both treatments can "create substantial suffering," according to the Swedish investigators.

Of course, the radical prostatectomy can also cause substantial suffering because urinary incontinence and impotence are the known complications for a sizable minority. However, in an entirely different study coauthored by Dr. Johansson in 2002*, the men who had been treated with radical prostatectomy were surprisingly tolerant of these side effects. Their self-reported well-being was no different, after four years of follow-up, from the men in the watchful waiting group.

Significantly, the study of untreated Swedish men began before the introduction of the PSA screening blood test for early prostate cancer. The men had been diagnosed incidentally when prostatic tissue was removed during surgery for an enlarged prostate. Or, their tumors had become large enough to be found during a rectal examination. The tumors in the Swedish study were, therefore, larger than those currently detected in the U.S. where prostate cancer is usually found as a result of widespread PSA testing. Smaller cancers, detected by screening, are even more likely to remain dormant than those in the Swedish study.

What's the bottom line for these 223 untreated men? How many would have had their lives prolonged had they been given immediate prostatectomy and how many would have--in today's world of prostate cancer care--been treated unnecessarily? Here's a summary:

--The mean age at diagnosis was 72 years

--25 men died from prostate cancer within 15 years of diagnosis

--another 10 men died from prostate cancer after 15 years

--23 men are still alive

--of the 119 men who were over the age of 70 years at diagnosis, 106 died of causes other than prostate cancer

--of the 13 men who were under the age of 60 years at the time of diagnosis, three died of prostate cancer and three died of other causes

--89 men experienced progression of prostate cancer and in nearly half of these men, the disease remained in the area of the prostate

--estrogen therapy or surgical removal of the testicles, the current standard treatments for men whose prostate cancer has progressed beyond the prostate, might be worse than a radical prostatectomy

--three men who died from cardiovascular disease while undergoing estrogen treatment were counted as prostate cancer deaths

--if a radical prostatectomy had been given to all the men at the time of their original diagnosis, 18 would have experienced prolonged survival. (This estimate is based on an entirely different 2002 trial showing that prostatectomy prevents approximately half the prostate cancer deaths. Unfortunately, the same trial showed that the rate of deaths from all causes for the prostatectomy group was the same as that of the watchful waiting group.)

--205 men would have been given a prostatectomy that would not have affected their survival

Bottom Line: Men over the age of 70 years should consider refusing to undergo a PSA blood test when no prostate cancer symptoms are present

* 695 men had been randomly assigned to either prostatectomy or watchful waiting and followed for six years (Lars Holmberg et al, New England Journal of Medicine).

COPYRIGHT 2004 Center for Medical Consumers, Inc.
COPYRIGHT 2004 Gale Group