By: Dan Sperling, MD
One of the most venerable and respected peer-reviewed medical journals is the weekly publication Lancet, which publishes original research articles. In addition to the general weekly edition, Lancet also publishes specialty editions including one devoted to cancer, Lancet Oncology. In February of this year, the journal carried a study of prostate cancer treatment complications other than the two most commonly reported (urinary incontinence and erectile dysfunction).[i]
While other complications—also called side effects or co-morbidities—may occur less frequently than urinary leakage and sexual difficulties, patients should be aware that both surgery and radiation come with a broader range of risks. In this respect, the article provides important information that patients have a right to know.
The Ontario, Canada authors did a “population-based retrospective cohort study,” meaning that they defined their target population (men who had undergone surgery or radiation to treat their prostate cancer) during their designated study period (seven years between 2002 and 2009). They identified 32,465 patients who fell within their definition; they also identified 32,465 matched controls with no history of prostate cancer as a basis for comparison. They then examined existing clinical records to create a data pool on their diagnosis, treatment, and follow-up. Their sources included Ontario cancer registry data, hospital administrative data, and physician billing codes. They measured the 5-year cumulative incidence of events that specifically resulted from the patients’ treatment: hospital admissions; urological, rectal or anal procedures; open surgical procedures; and secondary cancers. This table shows the percentages:
|Admission to a hospital for treatment-related complication||
|Admitted longer than 1 day||
|Urological procedure required||
|Rectal or anal procedure required||
|Open surgical procedure required||
|Development of secondary primary cancer||
When compared with the control population, the percentages showed that the risks were significantly higher for those who were treated with surgery or radiation.
The article reports that factors such as old age and other serious medical conditions at the time of treatment were predictive of higher complication rates. However, the strongest predictor for complications was the type of treatment. Radiation patients had higher rates of hospital admission, rectal or anal procedures, open surgeries, and secondary cancers at five years than those who underwent surgery. On the other hand, Patients who were given radiotherapy had higher incidence of complications for hospital admissions, prostatectomy patients had a higher rate of urological procedures.
Based on their findings, the authors concluded that complications after prostate cancer treatment occur frequently, and may be aggravated by factors such as age, co-existing medical conditions, and the type of treatment. They advise that both physicians and patients discuss all risks of each treatment, and take those into account along with the effectiveness and benefits of each.
In contrast to the Lancet Oncology article, an article published around the same time in Recent Results in Cancer Research suggests that men with low-risk, early stage prostate cancer embrace a strategy of conservative management (Watchful Waiting or Active Surveillance) as a way to defer treatment.[ii] This article points to the PIVOT trial (Prostate Cancer Intervention Versus Observation), which seems to point to similar long term survival rates among men whose cancer is not treated compared to those who undergo surgery, radiation or brachytherapy. Recognizing the complication rates associated with treatment, this publication points to conservative management as a way to avoid the harms of treatment. It suggests in particular that for men with a life expectancy less than 15 years, such a strategy “will reduce diagnostic and treatment related harms without adversely impacting overall or disease specific mortality and morbidity.”
When taken together, these two articles point to the need for a happy medium between total gland treatment with its attendant risks, and deferring treatment with its attendant anxiety burden—and the risk of missing a treatment window. The rapidly growing interest in focal prostate cancer ablation is testimony that both patients and their doctors are seeking the best way to achieve maximum cancer control with minimum impact on wellness and quality of life. With the advent of more cancer-specific screening tests, high resolution imaging, and targeted biopsies, it is vital that all men have affordable access to emerging middle-ground therapies.
[i] Nam RK, Cheung P, Herschorn S, Saskin R et al. Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study. Lancet Oncol. 2014 Feb;15(2):223-31.
[ii] Wilt TJ. Management of low risk and low PSA prostate cancer: long term results from the prostate cancer intervention versus observation trial. Recent Results Cancer Res. 2014;202:149-69.