Colon rectal cancer symptom

When a man is diagnosed with early prostate cancer, he faces several options but no clear answer to the most crucial of all questions: Is treatment better than no treatment at all? A new Swedish study showed that surgical removal of the prostate does, in fact, reduce a man's odds of dying of prostate cancer but worsens his quality of life.

Unfortunately, the finding has little relevance to most American men because prostate cancer screening has become so popular in this country that the majority are diagnosed before they have any signs or symptoms of the disease. And this was not true of the majority of the Swedish men who participated in the study published last month in The New England Journal of Medicine (9/12/02).

Americans Diagnosed Earlier

The term early means that the cancer has not spread beyond the prostate gland. But there are degrees of "early." The majority of the Swedish participants had tumors that could be felt by a digital rectal examination, and many had symptoms, such as difficulty urinating. Whereas 75% of American men with prostate cancer do not have a tumor that can be felt, nor do they have symptoms. They are diagnosed after a biopsy ordered as a result of a PSA screening test. The Prostate-Specific Antigen (PSA) test identifies a protein in the blood that can indicate the presence of a cancer too small to be felt. Originally intended as a follow-up test for men who had been treated for prostate cancer, the PSA test has been promoted to symptomless men for over a decade.

The relatively small group of newly diagnosed American men who fit the profile of the 695 participants in the Swedish study should take note: The results of this study are a wash. At six years, the men who had a prostatectomy (surgical removal of the prostate) had a lower death rate from prostate cancer, but it was canceled out by a higher death rate from other causes. If the aim is solely to reduce the odds of dying of prostate cancer within the next six years, then surgery is the way to go. Only 4.6% of the men died of prostate cancer after undergoing a radical prostatectomy; where 8.9% of the untreated men died of the disease.

If, however, the goal is to lower the odds of dying from any cause, then no treatment is the way to go. The overall death rate in both groups was exactly the same. It is possible that the surgically treated men died of treatment-related causes, such as an infection. In that case, their deaths would not be counted as prostate cancer deaths. All the men were under the age of 75, with an average age of 64 years.

By counting the overall death rate--that is, the deaths from all causes--he authors of this study are following an important new trend in research. They are stepping back and looking at the big picture, as opposed to looking solely at the question of whether X medical treatment lowers the death rate from Y disease. Too often, the treatment itself will cause deaths, but they go uncounted by most researchers. Here is the conclusion of the Swedish study: "...there was no significant difference between surgery or watchful waiting in terms of overall survival," wrote Lars Holmberg, MD, and colleagues at the Scandinavian Prostatic Cancer Group Study.

The Swedish research team noted that there were 37 deaths from other causes in the surgically treated group and 31 in the untreated group. "This difference could be due to chance or to long-term but hitherto unknown adverse effects of prostatectomy."

While it is unusual for researchers to address the overall death rate in the conclusion of their study, the finding itself is not. There are already several examples of medical interventions that reduced the death rate from cancer but failed to reduce the overall death rate. For example, several randomized controlled trials showed that screening tests for colon cancer reduce the rate of deaths from this disease but inexplicably increase the death rate from heart disease. More recently, a review of all the best mammography clinical trials came to a similar conclusion about the overall death rate.

Now for the question of quality of life. It's certainly possible that a prostatectomy could improve a man's life without prolonging it. Consequently, the Swedish research team sent questionnaires to the 326 men who had symptoms at the start of the study to see how they fared four years later. The percentage of men suffering the following symptoms was consistently higher among the surgically treated, as compared to the untreated: impotence (80% vs 45%), "distress from compromised sexuality" (55% vs 40%), urinary leakage (49% vs 21%), "distress from all urinary symptoms" (27% vs 18%).

The clinical trial with the most relevance to American men is currently in progress, and results will not be available until 2008. It is sponsored by the Department of Veterans Affairs, the National Cancer Institute and the U.S. Agency for Health Research and Quality. The 731 participants had cancer that was confined to the prostate and most were diagnosed initially with a PSA test. Like the Swedish study, the men were randomly assigned to have their prostates removed or to remain untreated. The lead researcher Timothy J. Wilt of the Minneapolis VA Medical Center recently told The New York Times that five years into the study, no survival advantage has been shown for either group.

Although there are other treatment options for men with localized prostate cancer, such as radiation therapy and radiation seed implants, no head-to-head comparison study has ever been done.

SIDE BAR

NO PROOF YET THAT PSA TEST SAVES LIVES

Why go searching for prostate cancer in symptom-free men when no treatment is a valid option once you find something? No one dares ask that question any more because the prostate-specific antigen, or PSA, test has become an accepted component to the yearly check-up for all men over the age of 50. An unfortunate trend given the considerable risks of this test, namely, the detection and treatment of a cancer that would have remained latent an entire lifetime. The overwhelming majority of prostate cancers are in this category, but a small minority are aggressive and lethal.

The problem is this: Doctors still cannot accurately identify which is which. And even if the aggressive prostate cancers could be identified at an early stage, there is no proof that immediate treatment is lifesaving. The PSA has reached a level of popularity among primary care physicians that many include it in the blood work ordered during a routine physical without informing their patients.

The National Cancer Institute (www,cancer.gov) and most other policy-setting organizations do not recommend PSA screening because there is no evidence that the benefits outweigh the risks. An ongoing clinical trial is expected to provide some answers.v

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MaMaryann Napoli is the associate director of the Center for Medical Consumers in New York CIty.