Shahar Madjar, MD, Journal columnist

In Oxford, England, a group of doctors and scientists have been following men diagnosed with prostate cancer for more than two decades.

Why is there a need to follow patients with prostate cancer for such a long period of time? It’s because the disease, despite being called ‘cancer,’ often takes a prolonged course. Any treatment for prostate cancer should therefore be evaluated over a long period of time, in order to clarify whether the treatment is indeed effective, better than other treatment options, or even better than doing nothing at all.

The word ‘cancer’ in ‘prostate cancer’ indicates that, at times, prostate cancer cells can invade adjacent structures and can spread to lymph nodes, bones and other organs. It can lead to a widespread metastatic disease and eventual death. In 2020, in the U.S., for example, approximately 192,000 men were diagnosed with prostate cancer and 13,000 died of the disease.

The researchers from Oxford analyzed the outcomes of different treatment options in a group of 1,643 men with prostate cancer. All of these men were diagnosed based on an initial abnormal PSA testing (a blood test used to screen men for prostate cancer) followed by prostate biopsies that confirmed the diagnosis.

Once the diagnosis of prostate cancer was made, the patients were divided into three groups, each contained a similar number of patients, about 550 patients in each group. One group was treated with prostatectomy (surgical removal of the prostate), another group received radiation treatment, and the third group of men was only monitored without initial surgery or radiation.

After 15 years of follow-up, death from prostate cancer occurred in only a small group of patients and the rate of death from prostate cancer was low (2.7%) and was similar in all three treatment groups. The rate of death from causes other than prostate cancer was much higher and stood at 21.7% (while the patients were waiting to die of their prostate cancer, they actually died of other causes. In other words, they die with their disease not from it). The rate of death from other causes was also similar among the groups.

Reading these results, one can conclude that no matter what a patient with prostate cancer does, the end result will be similar and his chances to die of prostate cancer, even after 15 years from the time of diagnosis, is low. But a deeper dive into the results may lead to a more complex interpretation.

The men in the active treatment groups were treated with either radical prostatectomy or radiation. These treatments aren’t without risks. We know from other studies that radical prostatectomy, for example, can lead to urinary incontinence in a significant number of patients (24% according to a large, well designed study), and to erectile dysfunction.

In the Oxford study, the observation group (the group that didn’t receive initial active treatment such as prostatectomy or radiation) had death rates similar to the other groups, but other outcomes weren’t as good–in the observation group, the rate of metastases was almost double (9.4% vs. 4.7%-5%); the rate of worsening clinical conditions (clinical progression) was more than double (25.9% vs 10.5-11%); and the need for additional treatment in the form of hormonal therapy was also much higher (12.7% vs 7.2%-7.7%).

Hormonal treatment in prostate cancer aims at stopping testosterone production or blocking testosterone from acting on prostate cancer cells. To put it simply, prostate cancer cells “feed” on testosterone and in its absence they are likely to die or stop growing. Hormonal treatment isn’t without significant risks. The side effects of hormonal treatment include loss of libido, erectile dysfunction, hot flushes, night sweats, bone and muscle mass loss, fatigue, and depression, among other significant side effects).

In the Oxford study, patients in the observation group were monitored by serial PSA tests and if their PSA rose, they were offered active treatment. At the end of the Oxford study, only about one quarter of the men (24.4%) who were initially observed were alive and without any additional treatments. The others were converted to active treatments: radical prostatectomy, radiation treatment, or hormonal treatment.

What is a man diagnosed with prostate cancer to do? I tell my patients that their chance to live a long life and to eventually die of other conditions, or of old age is excellent. I tell them that their chance of dying from prostate cancer is similar no matter which treatment option they choose.

As to the question of which treatment option is best, I look at their age and consider their general health and the severity of their prostate cancer. I describe the different treatment options and the side effects typical of each option. In the end, a decision is made based on the trade-off between harms and benefits.

It is a shared-decision that takes into account not only longevity but quality of life as well.

EDITOR’S NOTE: Dr. Shahar Madjar is a urologist at Aspirus and the author of “Is Life Too Long? Essays about Life, Death and Other Trivial Matters.” Contact him at smadjar@yahoo.com.