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Localized Prostate Cancer: Treat With Surgery or Wait?

US News & World Report - Health logo US News & World Report - Health 10/20/2020 S. Adam Ramin, M.D.

The debate over "watchful waiting" and prostate cancer treatment has been a topic in the urologic community for many years.

But one new study addressed a more specific question: How does the surgical removal of the entire prostate gland (known as radical prostatectomy) compare with the decision to defer, or wait on treatment? Studies like these can help men make more informed decisions about prostate cancer treatment, under the care of an experienced and trusted health expert.

To answer the above question, the study authors combed through research and literature that included more than 2,600 men with prostate cancer. Each of the study subjects had either elected to have a radical prostatectomy or decided to delay treatment and actively monitor their prostate cancer instead. The authors concluded that based on long-term follow-up, radical prostatectomy likely results in improved cancer outcomes in men with localized prostate cancer. They also surmised that this treatment option probably reduces the risk that their cancer would progress or metastasize. Still, a radical prostatectomy is not without risk – urinary and sexual function are factors that must be taken into consideration and are some of the most significant reasons that skilled, highly-trained and experienced surgeons are essential when considering this type of treatment.

In general, this study's findings do substantiate what I tell patients who are newly diagnosed with prostate cancer. As a urologist and urologic surgeon, I always discuss the possibility of deferred treatment and active surveillance with my patients. However, it is essential to note that not all patients are candidates for active surveillance or deferred treatment. Many patients initially present with aggressive or high-risk features to their prostate cancer that makes waiting dangerous. These patients are not candidates for deferred treatment and should undergo surgery or other types of treatment upfront. However, many patients with prostate cancer have low-risk or less aggressive features and are good candidates for active surveillance. The prostate cancer in these patients may never progress to high-risk or more aggressive features, and therefore they may live the rest of their lives without needing treatment.


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On the other hand, the patients who display disease progression while on active surveillance should undergo treatment in a timely fashion. Thankfully, newer testing techniques on biopsy specimens containing prostate cancer cells may better predict the possibility of cancer progression on active surveillance. Therefore, the incorporation of molecular testing in evaluating some patients with apparent low-risk prostate cancer features can help more accurately identify the right candidates for active surveillance.

It's essential to consider that about 50% of patients on active surveillance for prostate cancer will eventually experience disease progression and need treatment. Unfortunately, some patients who chose active surveillance, develop a false sense of security and do not adhere to their provider's follow-up plan. They may fail to return for their follow-up exams and eventually develop incurable disease. Furthermore, there is no uniform protocol for the follow up of patients on active surveillance. Follow up requires periodic physical exams, PSA blood testing, repeated prostate biopsies and imaging such as MRI of the prostate or transrectal ultrasound of the prostate. However, there is no accepted or validated protocol on when and how often to obtain these tests. The art of handling active surveillance patients is to capture these tests before cancer spreads or becomes incurable.

Therefore, more research is needed to fully understand which types of prostate cancer patients are good candidates for active surveillance. Furthermore, many of the research articles with more than 15 years follow up are based on the older technique of open radical prostatectomy. With the advent of robotic surgery and prostate surgery consolidation to surgeons with high levels of experience, the rate of incontinence and erectile dysfunction may be improved compared to previous data. Therefore, quality-of-life assessment of patients undergoing robotic prostate surgery by experienced robotic surgeons may be higher than reported in this study.

Lastly, further research on the development of uniform protocols for active surveillance would also be beneficial. That way, men can make more fully informed decisions about what "watchful waiting" will require to avoid the progression of their prostate cancer.

Copyright 2020 U.S. News & World Report

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