Surgery for Prostate Cancer – Do You Need It?

Majid Ali, M.D.

If you have local prostate cancer and are between 50 and 69, surgery will not help you, so say the British who have national health service for all citizens. Read more about the ProtecT Trial below.


 

A quote from the report

“At a median follow-up of 10 years, the ProtecT trial showed that mortality from prostate cancer was low, irrespective of treatment assignment.”

Prostatectomy and radiotherapy were associated with lower rates of disease progression than active monitoring;” Notwithstanding, a ten-years follow-up showed no long-term benefits of surgery.


Here Is Something Else Interesting

Another quote from the article:

“Synthesizing these data, the U.S. Preventive Services Task Force recommended that population screening for prostate cancer should not be adopted as a public health policy, because risks appeared to outweigh benefits from detecting and treating PSA-detected disease.”


ProtecT Trial

A total of 545 men were randomly assigned to active monitoring, 553 to radical prostatectomy, and 545 to radiotherapy. The median age of the participants was 62 years (range, 50 to 69), the median PSA level at the prostate-check clinic was 4.6 ng per milliliter (range, 3.0 to 19.9), 77% had tumors with a Gleason score of 6 (on a scale from 6 to 10, with higher scores indicating a worse prognosis), and 76% had stage T1c disease;


X.  Hamdy FC, Donovan J, Lane JA, et. al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer.N Engl J Med 2016; 375:1415-1424

N Engl J Med 2016; 375:1415-1424October 13, 2016DOI: 10.1056/NEJMoa1606220


The ProtecT Trial

The management of clinically localized prostate cancer that is detected on the basis of prostate-specific antigen (PSA) levels remains controversial. In the United States alone, an estimated 180,890 cases will be diagnosed in 2016, and 26,120 men will die from the disease.1 The widespread use of PSA testing has resulted in a dramatic increase in the diagnosis and treatment of prostate cancer, but many men do not benefit from intervention because the disease is either indolent or disseminated at diagnosis. Prostate cancer often progresses slowly, and many men die of competing causes. In addition, interventions for prostate cancer can have adverse effects on sexual, urinary, or bowel function. Two treatment trials have evaluated the effectiveness of treatment, but they did not compare the most common contemporary methods: surgery, radiotherapy, and monitoring or surveillance.2-4

The National Institute for Health Research–supported Prostate Testing for Cancer and Treatment (ProtecT) trial recruited men 50 to 69 years of age in the United Kingdom. From 1999 to 2009, a total of 82,429 men had a PSA test; 2664 received a diagnosis of localized prostate cancer (including 146 men from the feasibility study), and 1643 agreed to undergo randomization to active monitoring, radical prostatectomy, or radiotherapy. Here we report the effectiveness of each intervention in relation to prostate-cancer–specific mortality and all-cause mortality and the incidence of metastases and disease progression at a median of 10 years of follow-up in the randomized trial. In a companion article, we report complete patient-reported outcomes in the randomized cohort at 6 years of follow-up.5

Participants

A total of 545 men were randomly assigned to active monitoring, 553 to radical prostatectomy, and 545 to radiotherapy. The median age of the participants was 62 years (range, 50 to 69), the median PSA level at the prostate-check clinic was 4.6 ng per milliliter (range, 3.0 to 19.9), 77% had tumors with a Gleason score of 6 (on a scale from 6 to 10, with higher scores indicating a worse prognosis), and 76% had stage T1c disease; there were no meaningful differences at baseline among the three randomized groups.6 Information on baseline demographic and clinical characteristics according to assigned treatment group is provided in Table S2 in the available with the full text of this article at NEJM.org.

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