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Most Low-Risk Prostate Cancer Patients Receive Aggressive Treatment

Study suggests many men may be treated unnecessarily

A new study reports that most men with low-risk prostate cancer are nevertheless undergoing aggressive treatment in the form of radiation therapy or surgery, both of which can have significant side effects like impotence or incontinence.

A team of researchers reviewed data collected by the National Cancer Institute on more than 123,000 men, age 25 and older, who were newly diagnosed with prostate cancer between 2004 and 2006. It’s the first large-scale study to report the type of treatment received by American men with low-risk prostate cancer.

Prostate cancer is the most common cancer diagnosed in men. It can be slow-growing and is not always fatal.

The study looked at the results of a common blood test that screens for prostate cancer by measuring a man’s prostate-specific antigen (PSA) levels. A PSA level lower than 4.0 is generally considered safe, though a small percentage of men with lower levels have an aggressive form of prostate cancer. A number of factors can influence doctors to recommend biopsy when PSA levels are over 4, including symptoms, family history, increasing PSA scores or the size of the prostate.

The researchers found that more than 70 percent of men with PSA levels lower than 20 received either radical prostatectomy—surgery that removes the entire prostate gland plus some surrounding tissue—or radiation therapy, and 44 percent of men with PSA levels below 4 had the radical surgery.

Fourteen percent of all the newly diagnosed men had a PSA level lower than 4, which put them in a low-risk category. More than half of that group also had a low Gleason score, meaning the tumor was slow-growing and not likely to spread. Most men with these low-risk cancers are not likely to die of prostate cancer.

“You might say that if any group could have less aggressive treatment, that’s the group you would look at,” says Robert DiPaola, M.D., coauthor of the study and director of the Cancer Institute of New Jersey. “But yet 75 percent of that group had some form of more aggressive treatment—any form of radiation therapy, including seed implants, or surgery.”

When the group of men with low-risk cancer was broken down by age, 40 percent of men 75 and older and 66 percent of men age 65 to 74 received aggressive treatment. And almost 80 percent of younger men ages 55 to 64 received more aggressive treatment.

“The message is not that they shouldn’t be treated,” says DiPaola, “but that they should sit down with their physicians and have an informed discussion about their PSA, the aggressiveness of the tumor, their likelihood of dying of prostate cancer and then make their decision.”

Richard Hoffman, M.D., of the University of New Mexico Cancer Center in Albuquerque who wrote a commentary on the study, agrees. “Men get the message ‘you have cancer’ ” he says. “They don’t realize there are these low-risk prostate cancers, and they should understand all their options.”

One of these options is called “active surveillance,” where patients and their doctors follow the cancer, continue to do PSA tests and biopsies, and adapt treatment decisions accordingly. “Remember, you don’t have to make a decision right away,” says Hoffman. “If the cancer starts out as low-risk, with active surveillance you may have  years to decide whether to undergo aggressive treatment.”

The study was funded in part by the National Cancer Institute and the Robert Wood Johnson Foundation. The results and the commentary appeared online in Monday’s Archives of Internal Medicine.

Cathie Gandel is a writer in Bridgehampton, N.Y.

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