Prostate Cancer - Surgery often not justified

 

Recent studies confirm overtreatment / Serious side effects for patients after surgery

The majority of patients in Germany diagnosed with localized prostate cancer are still undergoing radical surgery. That this procedure has been obsolete for quite some time has meanwhile been evidenced by numerous studies. Especially for men with low risk tumors or men over the age of 70, radical prostatectomy might not be a wise decision. On the contrary: Many patients complain of significant side effects after the surgery—and this, although vessel and nerve-sparing surgical techniques are used more frequently.

 


The fact is prostate cancer is now discovered more often at an early stage due to improved screening methods. However, at the same time, uncertainty exists whether all diagnosed tumors need invasive therapy, such as radical surgery. Because we know now that many of these tumors would never cause symptoms, let alone lead to death. "Reaching for the scalpel happens all too often" criticizes Dr. Stefan Neubauer, urologist at West German Prostate Center. Men with prostate cancer generally undergo surgery prematurely without the option of a more gentle treatment, such as the "watchful waiting" (doing nothing or active surveillance) being considered.

More harm than good.

Numerous studies, including a recent study1 published in the New England Journal of Medicine confirm the theory that too many men who had undergone radical surgery did not enjoy long-term benefits. On the contrary, the proportion of men who are incontinent within two years (17% versus 6%) or impotent (81% versus 44%) is significantly higher in patients who had radical surgery than in patients who were not treated with radical surgery. 
Similar results were also shown in a recent study of the Health Insurance Company Barmer GEK2. According to this study, 70 percent of those having had surgery complained about erectile dysfunction, 53 percent about sexual disinterest, and over 16 percent complained about urinary incontinence. One in five patients also confirmed surgery-related complications such as excessive bleeding or bowel injury.

A Swedish study also found that particularly prostate cancer patients with non-palpable, less aggressive tumor (T1 tumor, a Gleason score below 7) and men over the age of 70 do not benefit from invasive surgery.  But also for patients whose tumor characteristics are unfavorable (T1 tumor, Gleason score 7 / T2 tumor, Gleason score 6), the advantage of an invasive treatment, such as surgery, can according to scientists not be verified conclusively.

"An extended radical removal of the prostate does in many cases not prolong life, but does in a worst case scenario significantly reduce life quality", says Dr. Neubauer. In the current research situation, the question arises whether a more radical approach to treatment is justified in every case.  Instead, the aim should rather be to achieve the best recovery in combination with minimal side effects. Suitable for this are primarily minimally invasive techniques, such as internal radiation. During the so-called brachytherapy, smallest radiation sources are placed directly into the prostate under ultrasound control. Thus, brachytherapy has a major advantage over radical surgery: "Through an exact distribution of the radiation dose, we can irradiate the tumor without damaging surrounding structures such as the urethra or urethral sphincter ", so Dr. Neubauer.

Recent meta-study: brachytherapy superior to surgery 

Brachytherapy is not only convincing because it results in lesser complications and side effects but also in terms of effectiveness: Thus a recent meta-study (summary of worldwide study data), demonstrated for the first time that brachytherapy, by itself or in combination with an additional radiation or hormone therapy, provides in comparison to radical surgery at least as good or even better cure rates. "This will allow the patient to meaningfully combine the advantage of an optimal tumor cure with the in comparison to radical surgery fewer side effects of a brachytherapy", says Neubauer.

1 Wilt TJ, Brawer MK, Jones KM et al.; Prostate Cancer Intervention versus Observation Trial (PIVOT) Study Group. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med. 2012 Jul 19;367(3):203-13.
2 Barmer GEK Krankenhausreport 2012
3Vickers A, Bennette C, Steineck G, Adami HO, Johansson JE, Bill-Axelson A, Palmgren J, Garmo H, Holmberg L. :Individualized Estimation of the Benefit of Radical Prostatectomy from the Scandinavian Prostate Cancer Group Randomized Trial.Eur Urol. 2012 Apr 19. [Epub ahead of print]
4Grimm P, Ignace Billiet I, Bostwick D et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl. 1, 22-29, 2012