I have been asked by hundreds of men who have been diagnosed with prostate cancer whether they should be treated with surgery or radiation, or just watch and wait. One study showed that men under 60 who are in excellent health and are destined to live long lives may benefit from early treatment (1). Six years later, 4.6 percent of men who had surgery had expired, compared to 8.9 percent of those who did not have surgery. This is statistically significant and shows that prostate cancer surgery prolongs life in men under 60. However, the results of prostate cancer surgery are very controversial. We know that to save one life, you have to operate on many men who will not benefit from the surgery. The surgery can cause impotence and loss of ability to hold urine. In March 2009, the New England Journal of Medicine published two studies. One showed that prostate cancer surgery prolongs lives, while the other shows that it does not (2). Current feeling by most urologists is that surgery for men under 70 may prolong lives, while little data show life prolongation for men over 70.
About five percent of prostate cancers grow rapidly and can kill. Unfortunately, doctors do not have a reliable test that tells them which prostate cancers will kill. Most prostate cancers grow very slowly. Untreated prostate cancers can take 22 years from diagnosis to death. A study in the Journal of the American Medical Association (3) followed men with early stage prostate cancer who were cared for without surgery or radiation. Ten years later, only six percent had died from prostate cancer.
In various studies, up to 30 percent of men treated with surgery, radiation or hormone therapy for prostate cancer suffer from some degree of impotence or incontinence. We don’t even know if 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. Most 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. However, special machines at Loma Linda and other specialized centers are less likely to cause this destructive side effect.
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 little evidence that surgery prolongs the lives of men with prostate cancer that has already spread. Men who have prostate cancer that has spread are usually treated with drugs to block 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.
I recommend watchful waiting for many 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 are likely to die of something else before their cancer spreads, but many urologists disagree with me.
PSA blood test to screen for prostate cancer
1) NEJM September 12, 2002
2)NEJM, March 2009: 360:1320-8; 1310-9
3) JAMA, September 15, 2009