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Delayed Surgery May Be OK for Some Prostate Cancer Patients

February 28, 2006

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Delaying surgery -- even for years -- for patients with small, low-grade prostate cancer does not appear to increase the risk of the disease progressing to an incurable form, according to a 10-year Johns Hopkins Medicine study.

The study, published in the March 1 issue of the Journal of the National Cancer Institute, found the risk of noncurable prostate cancer -- defined as a less than 75 percent chance of remaining disease-free 10 years after surgery -- was the same for men receiving immediate surgical treatment and those who waited -- on average -- two years before surgery.

Last month, researchers at the Veterans Affairs (VA) Connecticut Healthcare System and Yale School of Medicine reported that a screening test for prostate cancer that measures prostate-specific antigen (PSA) levels does not improve survival.

"This study suggests that for carefully selected men with prostate cancer who are monitored, the window of cure does not close in the short term. For those men diagnosed with early-stage, low-grade prostate cancer, an alternative to immediate surgical treatment would be careful surveillance," says H. Ballentine Carter, M.D., a professor of urology at the Johns Hopkins School of Medicine and senior author of the study.

Some researchers believe delayed treatment combined with an active surveillance program could decrease over-treatment. Others, however, believe postponing surgery might shift the patient outside the window of curability.

Men screened for prostate cancer with the prostate specific antigen (PSA) test are on average diagnosed with the cancer 10 years earlier than men not undergoing PSA screening.

While early diagnosis may contribute to a decrease in prostate cancer mortality in some patients, it may lead to invasive treatments of a cancer that may never present a health risk to the patient.

Carter says Hopkins has been enrolling patients in a monitoring program since 1995 with great success, although some patients prefer to go ahead and pursue treatment for "piece of mind."

"Some patients who learn they have cancer are anxious to have treatment 'yesterday'. We hope this study will illustrate that in many cases a safe alternative to immediate treatment is surveillance," Carter says. "Specifically, these would be men with small, low-grade tumors."

Three-hundred and twenty men believed to have these kinds of tumors have been enrolled in an active surveillance program since 1995.

Small, low-grade prostate cancer was defined as having a PSA density (PSA divided by prostate volume) below 0.15, no more than two biopsy cores involved with cancer, no biopsy core that showed more than 50 percent cancerous tissue and no high-grade cancer.

Thirty-eight of these patients delayed surgery for a median 26.5 months. Outcomes in these men were compared with a similar group of 150 men who had surgery after a median three months. Results showed that the risk of noncurable prostate cancer was the same for both groups. Factors associated with risk of non-curable prostate cancer included age at time of diagnosis, PSA level and PSA density.

Carter said his group is now studying blood and tissue samples from this population to better understand what puts patients at risk while they're being monitored. He said they plan to look at biomarker changes, genetic factors and lifestyle choices.

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