Prostate Cancer

Or a chance to cut really is a chance to cure.

Radical prostatectomy for prostate cancer is life saving, at least in men under 65, according to a new study in this weeks NEJM (subscribers, but NYT article here). In general prostate cancer is slow growing and men are more likely to die with it, than of it. So who should get potentially curative surgery and who should be treated less aggressively is still not clear. Other options are watchful waiting and use of radiotherapy implants which help control local disease but aren’t curative.

This study, from Sweden, randomized men with prostate cancer that hadn’t yet spread beyone the prostate (that could be detected) to watchful waiting or surgery. Radical prostatectomy (RP) is pretty brutal surgery where they remove the prostate and surrounding lymph nodes. Important structures are packed pretty tight down there, so the risk of collateral damage is high. Most (perhaps all) surgeries currently are “modified” or “nerve sparing” to try to preserve bladder control and erectile function, but more than 1/2 of men are impotent and ~10% incontinent. My impression is that this is a surgery you want done by an expert, because surgeons who do a lot have much better results. Patrick Walsh, a urologist at Johns, developed the nerve-sparing surgery, and all over the US his trainees are chiefs of urology and experts in the surgery.

The study showed that there were significantly fewer deaths in the surgery group, as well as fewer metastases 10 years after surgery. The benefit, on retrospective analysis, was confined to men under 65, who are likely to live longer. The study also didn’t differentiate between aggressive and less-aggressive tumors.

Raw numbers were as follows: watchful waiting 348 patients, 106 total deaths and 50 deaths from prostate cancer; RP 347 patients, 83 deaths, 30 deaths from prostate cancer.

So for patients <65, and perhaps older patients who would otherwise live a while, RP is probably the way to go. They’ll continue following their patients so we’ll see if the effect increases with more follow up.