To Treat or Not to Treat; That is the Question – At Least for Prostate Cancer

Cody Wolf

I’m sure that many of our readers know (or at least you will in a few moments) that I am a cancer researcher. It of course makes sense then that one of my first blog posts is on cancer. I also happen to study prostate cancer. This article came across my desk recently and I could not help but share it with the Copernicus Called Family.

So….Here Goes.

cancer-cell
Source

Cancer is by far one of the largest threats that currently looming over societies head.Prostate cancer is especially worrisome, being the third leading cause of cancer deaths in the United States for males; behind lung and colorectal (colon) cancer [1]

That being said, being diagnosed with prostate cancer does not necessarily indicate a painful or tragic death. In fact, a recent article in The New England Journal of Medicine sought out to study exactly when treatments are necessary for prostate cancer patients……and when watching without conventional treatment may be the best option.

Although prostate cancer still is high on the list for mortality in men, many patients are diagnosed at a very early stage. Currently Stage 1 and stage 2 prostate cancer (tumor contained within the prostate, no lymph node metastasis, no metastasis to other organs) has a 5 year survival rate of 99%. That’s pretty great. And  later stages of prostate cancer have a high survival rate (nearly 100%) even though the cancer has potentially spread to nearby areas (regional lymph nodes)

So, I mean, this is all pretty good news right? The only downside is of course cancer that has spread to distant areas of the body (brain, liver, bones), which has a survival rate of 29%. Not the best. [2]

But, fortunately many men who are diagnosed usually fall into the Stage 1 to Stage 2 category. About 4 out of 5 cases actually. [2]

Therefore, medical doctors are faced with the question on how to treat early stage prostate cancer.

Back in the good ole’ days, prostate cancer was considered a major issue, even at Stage 1.

Men would get checked, blood and pee would be analyzed, and then prostates would be cut. Pretty routine procedure that did indeed prevent cancer. The official term is radical prostatectomy (removing the whole prostate and neighboring tissues). There are various methods for surgery. If you would like to read more about the subject, please follow this link.

But…there’s a small problem. Side effects from a radical prostatectomy aren’t the best. These include incontinence (leaking of urine from the urethra) and incompetence (do I need to explain this one?). For a man potentially in his 40’s, the downsides of surgery are just a little bit daunting.

best-doctors-established-by-doctors-used-all-around-the-world_image715_292
Source

 

So what can physicians do?

The best way to determine whether or not surgery should be performed regardless of the consequences, is to study whether or not it has a major effect on survival for patients.

Turns out… for the early stages of prostate cancer, we may want to hold the scalpel.

The study previously mentioned supports the hypothesis that a radical prostatectomy is just a bit overkill.

At this time it’s important to note that this study is not the only one to propose this idea. In fact, the authors of this current study published something similar four years ago.

And there have been a few other sources that favor this hypothesis.

Let’s get into this study.

731 lucky patients with localized prostate cancer were divided into 2 groups. One group received radical prostatectomy surgery, and the other received nothing but observation (medical doctors call this active surveillance or watchful waiting).

Now you may be wondering how long the study lasted. 5 years? 10 years? Well in reality, it was more like 15-16 years. Patients were randomly assigned from 1994-2002 (do not confuse this with the length of the study, this is how long they were selecting patients), and then all patients were observed until August of 2014. Quite a long time.

The Data

calculator
Source

Well, after the study, 64% of the men had died. This may sound devastating, but we must remember that the majority of males diagnosed with prostate cancer are older, and this study has the average age at 67 years. Not spring chickens.

The researchers address this by determining the “all cause mortality” or in layman’s terms, dying from anything. What they found is that there was no significant difference in those who received treatment, and those who did not. Note: Statistical significance is extremely important in research, and this will be discussed more thoroughly in another blog.

Another powerful piece of data is the comparison of those who died due to prostate cancer rather than non-related deaths. Death by cancer occurred in 69 men, or 9.4% of those in the study. 65 deaths were attributed to prostate cancer and 4 to treatment complications.

Death due to prostate cancer occurred in 7.4% of those in the surgery group, and 11.4% in the observation group. Again the differences between the two groups are not significantly different.

Another aspect of this study that is interesting, is what the patients thought of different treatment conditions. Subjects were asked to fill out a Medical Outcomes Study 12-Item Short-Form General Health Survey (from what I can gather it’s just a fancy name for a survey to asks how patients feel about their treatment).

Overall, worry about health did not differ between groups. But, the interesting fact is that men who received surgery reported more complications due to prostate cancer or treatment, physical discomfort, and limitations to daily activities. Incontinence also was an issue with those who underwent surgery, and erectile dysfunction occurred in a significant portion of those who visited the surgeon’s table.

There is a touch more to the study, but we will not cover those in the blog today. If you are interested, and want learn more, follow the link to the study.

Now, so far I have talked about this study as if it’s the finality of the topic, but really it’s not.

One of the main issues I have with this study is the statistical significance. As mentioned above, we will discuss this in much more detail at a later time, but I can’t help but get this off of my chest now.

Officially, a set of data is considered significant if the p value is at or below 0.05. In our context, this number would suggest that the probability that those treated with surgery and those not will have different outcomes (i.e beneficial to have surgery). This suggests that there is a 5% chance that the surgery is actually beneficial to patients.

If the p value is higher than 0.05, let’s just take a hypothetical number, 0.45. This hypothetical value suggests that 45% chance that the surgery is beneficial to patients.  So at that point, is it worth having the surgery, if it means that your sexual function is eliminated, or if you are forced to wear a pad due to a leaky urethra?

The p values for the study are just barely over the line of significance. For the overall mortality rates, and the prostate related deaths examined in this study, the p values were 0.06. So 6% of patients who receive treatment will have no difference in outcome based off their treatments.

Technically… by standards set, 0.06 is not a statistical significance. But it’s pretty damn close.

Let me be as clear as I can. I am not trying to change the way science works, or how statisticians evaluate data, and I am not trying to knock what the study suggests here.

But I do want our readers to be thinking. “Is this study really the final word?” I will let you, as the reader make the final decision.

doctor-old man
Source

That being said, I do not oppose the active surveillance treatment method. I think it’s a perfectly valid method for prostate cancer patients who are in the early stages. As more studies are performed, researchers and clinicians will be able to make the best decisions for their patients.

Thank you all for reading! I have just a few notes to add to today’s blog:

 

If you happen to be reading this, and you have prostate cancer or have recently been diagnosed, please do not take this blog post as medical advice. I will always recommend that you speak to your medical team and discuss the best options for your specific case. If you are seeking answers to questions, I would ask that you visit cancer.org. This website run by the American Cancer Society has fantastic information on all types of cancers (and was a great source for me writing this blog) and can direct you to assistance you may need.

 

And finally, since I am already on my soap box, I would like to remind everyone who is at the age for testing (whether it be prostate, breast, colorectal, or any other type) of various cancers. Please go. It is worth it. A small amount of discomfort now can prevent a lifetime of suffering. Testing is the best way to detect cancer early. 

 

As always, questions can be submitted to our email account copernicuscalledblog@gmail.com, on Facebook (CopernicusCalled), or Twitter (@CopernicusCalled).

 

Remember to always be curious, and stay mindful! 

Works Cited

  1. “Key Statistics for Prostate Cancer.” American Cancer Society. January, 5th, 2017 https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html
  2. “Survival Rates for Prostate Cancer.” American Cancer Society. May 30th, 2017. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/survival-rates.html
  3. “Watchful Waiting or Active Surveillance for Prostate Cancer.” American Cancer Society. March 11th, 2016. https://www.cancer.org/cancer/prostate-cancer/treating/watchful-waiting.html
  4. “Surgery for Prostate Cancer.” American Cancer Society. March 11th, 2016. https://www.cancer.org/cancer/prostate-cancer/treating/surgery.html
  5. Wilt TJ, Jones KM, Barry MJ, Andriole GL, Culkin D, Wheeler T, Aronson WJ, Brawer MK. “Follow-up of Prostatectomy versus Observation for Early Prostate Cancer.” New England Journal of Medicine. 377:132-142. July 13 2017. DOI:10.1056/NEJMoa1615869. http://www.nejm.org/doi/full/10.1056/NEJMoa1615869
  6. Featured image credit-http://www.globalpatientservice.com/prosatate-cancer.php
Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s