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PROSTATE CANCER TREATMENT
I have been asked by hundreds of men who have been diagnosed with prostate cancer, whether they should be treated with surgery or radiation for prostate cancer, or just watch and wait. A study just reported in the New England Journal of Medicine suggests that young men who are in excellent health and are destined to live long lives may benefit from early treatment. The study shows that six years after surgery, 4.6 percent of men under 60 who had surgery for prostate cancer are dead from the cancer, while 8.9 percent of those who did nothing died of prostate cancer. This is statistically significant and shows that prostate cancer surgery prolongs life in men under 60. However, when the data are analyzed for men of all ages, prostate cancer surgery does not prolong life and it can cause impotence and loss of ability to hold urine.
Dr. Patrick Walsh is the chairman of the department of urology at Johns Hopkins and is one of the most respected authorities on the subject. He feels that that the six years that the men were followed is not long enough to show prolongation of life because prostate cancer is such a slow growing tumor. He feels that carrying the study out for more than ten years will show a reduction in death rate for all ages, but that is his opinion. I know of no studies showing that prostate cancer surgery prolongs lives in older men.
Before a man has his prostate removed, he should be told that surgery often prevents him from making love and can make him incontinent. It can destroy his image of himself as a man so that he becomes depressed and cannot function well in business, sports, or any other competitive endeavor. There are no studies to show that surgery is more effective in prolonging the lives of men with prostate cancer than brachytherapy, which is shooting radioactive needles into the prostate. Men who receive the radioactive needles are slightly less likely to become impotent and lose their urine. Beam radiation for prostate cancer has such a high rate of burning of the colon and small intestines that I do not recommend it ever to my patients.
If a man has prostate cancer that has spread to other parts of his body, he should not be abused with the surgery because there is no evidence that surgery prolongs the lives of men with prostate cancer that has already spread. Men who have prostate cancer that has spread somewhere else should be treated with drugs to block their male hormones, and when that fails a few years down the road, they should probably be given back testosterone, but add-back testosterone therapy is not yet proved to prolong lives either.
At this time I recommend radioactive needles for most men under age 70 with prostate cancer because so far the survival rates are the same and surgery causes a slightly higher rate of impotence and incontinence. I recommend watchful waiting for most men with localized prostate cancer over the age of 70 because the disease takes usually at least 20 years to kill and therefore most of these men don‘t need treatment because they may die of something else before their cancer spreads, but many urologists disagree with me. I recommend that men who have prostate cancer that has spread to other parts of their body take drugs to lower testosterone, and usually two years later, when the prostate cancer returns, they may need to take testosterone (again, add back tesosterone is not accepted treatment yet.)
NEJM September 12, 2002