What’s the best way to deal with prostate cancer (PCa)? The obvious answer is, do something about it. For decades, “doing something” meant radical prostatectomy (RP). In other words, surgically remove it all. More recently, the pendulum has started swinging the other way in a surge toward active surveillance (AS). From 2010 to 2015, the percentage of men choosing AS as a way to deal with low-risk disease rose from 14.5% to 42.1%.[i] Thus, for early stage PCa we’re moving from all to nothing at all as a way to defer treatment until it is clearly necessary. The question is, does delaying treatment raise the chance of dying from PCa? The evidence suggests that it does.
The Holmberg study
Let’s turn the clock back 17 years to a paper published in 2002 by Holmberg, et al.[ii] It reports a study in which 695 patients with localized PCa were randomly assigned to either RP or watchful waiting (WW), an earlier and more passive form of today’s AS. The men were enrolled between October 1989 and February 1999, with complete follow-up through 2000 (median 6.2 years). The research team tracked overall mortality, death from PCa, metastasis-free survival, and local PCa progression (evaluation of cause of death was blinded to which of the two groups the patient had been assigned).
Holmberg’s group found that in terms of overall survival there was no significant difference between the RP and WW groups. However, the men who were immediately treated with RP had significantly less risk of PCa-specific death (4.6% of RP patients) than those who were assigned to WW (8.9%). Also, the RP group had a lower risk of metastasis.
The Holmberg study in the long run
In 2018, a remarkable new paper out of the same institutions reported 29 years of follow-up (median 23.6 years) with the same 695 patients.[iii] In fact, Holmberg himself is one of the authors, so we congratulate him on being able to see his initial work come this far. By this time, 80% of the participants had died although none were lost to follow-up, so it’s virtually a complete data set.
Sixteen years later, the findings were essentially the same. In the RP group, 20% of patients died from PCa; in the WW group, 32% died from it. While 27% of patients in the RP group experienced distant metastasis, the rate was 44% in the WW group. The overall rates of death at 23 years’ follow-up were 71.9% in the RP group, and 83.8% in the WW group. Clearly, immediate RP gave a PCa-specific survival advantage vs. delaying treatment. In fact, on average the men in the RP group lived 2.9 years longer.
The 2018 paper also offers a richer understanding of the whole picture. The later data analysis divided participants by age at time of enrollment (< 65 vs. > 65). Also, a pathology examination of the RP specimens added information on features such as extracapsular extension (PCa outside the gland), showing that adverse pathology was linked with PCa-specific death. A 2019 commentary notes that
…a substantial proportion of younger patients with intermediate-high risk PCa benefitted from active treatment and had their life extended, on average, about 3 years…On the other side, patients with low-risk disease and older than 65 years old rarely die from PCa, confirming and underlying the pointlessness of creating harm with RP in this category of patients.[iv]
All, nothing at all, or something in between?
This brings us full circle to the opening question: what’s the best way to deal with prostate cancer? There is no simple black-or-white answer to this. If the issue is reduced to all or nothing, the 29-year follow-up of the Holmberg study seems to suggest that “all” is preferable to “nothing.” In this scenario, a man with early stage PCa who wants to live as long as possible and not die from his cancer should opt for RP and have it all immediately taken out. The longer the delay, the greater the threat of missing a potentially curative window.
However, there is an in-between solution that was not available when the Holmberg team began recruiting participants in 1989—nor would it be commonly available for over 20 years. For the right patient, focal treatment of the prostate cancer tumor using thermal ablation is a minimal treatment with maximum peace of mind.
Focal ablation greatly reduces, and in most cases avoids, the urinary and sexual side effects of RP. At the same time, it also relieves the anxiety of living with PCa growing in the gland.
At the Sperling Prostate Center, we offer MRI-guided Focal Laser Ablation for properly qualified patients. This outpatient treatment resolves the all-or-nothing-at-all dilemma by proving a middle ground that controls cancer while preserving quality of life.
The answer to the best way to deal with prostate cancer lies in treatments that can offer the best of both worlds to patients. We are proud to be leaders in today’s Focal Laser Ablation, perhaps something that clinicians like Holmberg and his team could only dream of.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Mahal BA, Butler S, Franco I, Spratt DE et al. Use of Active Surveillance or Watchful Waiting for Low-Risk Prostate Cancer and Management Trends Across Risk Groups in the United States, 2010-2015. JAMA. 2019 Feb 19;321(7):704-706.
[ii] Holmberg L, Bill-Axelson A, Helgesen F, Salo JO et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med. 2002 Sep 12;347(11):781-9.
[iii] Bill-Axelson A, Holmberg L, Garmo H, Taari K et al. Radical Prostatectomy or Watchful Waiting in Prostate Cancer – 29-Year Follow-up. N Engl J Med. 2018 Dec 13;379(24):2319-2329.
[iv] Afferi L, Zamboni S, Baumeister P, Mordasini et al. Prostatectomy versus watchful waiting in patients with localized prostate cancer: the survival benefit can be spotted in the long run. 18 April, 2019. doi: 10.21037/amj.2019.04.02 http://amj.amegroups.com/article/view/4915/html