Prostate Cancer Therapies About Equal

Men with prostate cancer who decide not to undergo surgery and instead opt to treat only the symptoms of their disease do just about as well as men who are operated on, at least in the initial six or seven years after diagnosis.

Neither strategy shields a man from serious side effects, such as impotence or urinary problems, although the spectrum of problems differs, depending on which therapy is chosen.

Those are the main conclusions of two studies, published in yesterday's New England Journal of Medicine, that examined one of the most controversial issues in medicine - how to treat prostate cancer. While the research produced no clear winner between therapies, it adds important details to the complicated picture of risks and benefits each patient must confront.

"The decision will still be difficult," said Lars Holmberg, a Swedish physician at Uppsala University, who helped lead the experiment. "But at least now we have a chance for better-informed guesses about a man's future than we did before."

Prostate cancer is one of the slowest-growing human cancers, and also one of the commonest. Small prostate tumors can be found in a majority of men who die in their eighties of other causes.

Some doctors oppose routine surgery in elderly men, and argue that a cure is unlikely, complications are common, and a patient is more likely to die of other causes before the tumor spreads and becomes fatal. Others argue that surgery is better, largely because doctors believe it extends life.

The debate was made more complicated in the last decade by the huge popularity of prostate specific antigen (PSA) testing, which measures the blood level of a protein made by growing prostate tissue, including tumors. PSA testing caused a spike of cancer diagnoses - and operations - in the early 1990s, especially in men who had no symptoms and were younger than the age at which prostate cancer had traditionally been found.

The Scandinavian study, which enrolled men from 1989 to 1999, straddled that period. Slightly more than half of patients had symptoms of prostate or urinary tract disease. In the rest, the cancer was found as the result of rectal examinations, PSA measurements and other tests.

In the experiment, nearly 700 Scandinavian men with prostate cancer were randomly assigned to either undergo potentially curative surgery or to use "watchful waiting" as the main approach to their disease.

Some of the men in the watchful-waiting group had surgery if they developed problems urinating. Many also received hormone or radiation treatments to shrink the size of their tumors (as did some of the surgery patients). None of those treatments was intended to cure them, however.

After about six years, 62 people in the watchful-waiting group had died, compared with 53 of those assigned to undergo an operation called a radical prostatectomy. Statistically, this outcome was a draw.