Prostate Cancer Surgery: Weighing the Risks and Benefits

It's been said that more men die with prostate cancer than from it. That statement is based in part on autopsy studies that revealed undiagnosed, untreated prostate cancer in many men. They died with the disease, which progresses slowly as compared to other cancers, not because of it.

All treatment options for prostate cancer have risks such as incontinence, impotence, and bowel problems. Because patients often live with prostate cancer until they die from another cause, and the potential negative effects from treatment are significant, the decision to treat the prostate gland involves a unique set of "pros and cons" to be weighed by doctors and patients. This is particularly true in the case where removal of the prostate gland is the appropriate treatment.

"Like a lot of statements, there's an element of truth in an absolute sense to the one that says more men die with prostate cancer than from it," said William A. See, MD, Medical College of Wisconsin Professor and Chief of Surgery (Urology). "But there's also the potential for those sorts of statistics to be abused.

"It's true that if you take out the prostates of all men who die and look for cancer, you'll see a large number of men who had cancer of the prostate and never knew it and died of something else relative to the number of men who actually succumbed to prostate cancer. But the cancers that we're identifying in those sorts of autopsy studies are likely very different than the sorts of cancers we're detecting in younger men."

For Older Men, Watchful Waiting
According to the American Cancer Society there were more than 220,000 new prostate cancer cases diagnosed in 2004. The disease kills about 30,000 men in the US each year.

"It is very important in making treatment recommendations to attempt to define the probability that a given patient's prostate cancer poses a threat to their survival," said Dr. See. "In fact, one of the first questions that should be addressed in the clinical setting when we counsel men about treatment decisions is whether in fact they need treatment at all.

"One of the management options for prostate cancer is something called 'watchful waiting.' It's a reasonable option in men who, based upon their tumor-specific variables, their age and their overall health, have a low risk of dying from their prostate cancer. As an example, if you have an 80-year-old gentleman who had what we would call well-differentiated carcinoma of the prostate, that looks indolent (slow to develop, relatively inactive) under the microscope, it would be appropriate for him not to seek curative therapy or active intervention.

"Because, as we look at his risk of dying from prostate cancer in that scenario, it would be very low. The risks posed to him by treatment relative to the risks posed to him by the disease itself would be disproportionate. So his risk-benefit ratio would be adverse for treatment for his prostate cancer."

Larger Window for Progression in Younger Men
The primary function of the highly cancer-prone prostate gland is to secrete the fluid that moves sperm forward during ejaculation. For younger men, the side effects of treating prostate cancer pose threats to quality of life that can last many years, while at the same time the risk of dying from the disease increases.

"Let's take that same individual now and let's make him a healthy 55-year-old," said Dr. See. "In that setting the window of opportunity for disease progression becomes much larger. The risk posed to that individual by his prostate cancer is likely to be far greater than for the 80-year-old, and consequently the risk-benefit ratio of treatment versus observation swings in favor of some intervention.

"It is a challenge to try to predict the future in terms of the individual patient's outcome. We would like predictors that are more black and white than exist today. But today there is an element, if you will, of art to counseling patients about appropriate options for the management of their disease."

Treatment Options Continue to Evolve
"The landscape around management options continues to evolve," said Dr. See. Take for example brachytherapy. Brachytherapy involves physically placing radioactive pellets inside the prostate to treat the cancer without surgery. "The trend in the past decade for greater use of seed implantation is seeing a reversal, driven by the recognition that seed implantation is over the long haul not nearly as benign as initially perceived and that it's not as effective an option for cure as was initially hoped.

"So people continue to look for treatment options that for them hold the best risk-benefit ratio. That's why it's very critical to customize treatment recommendations to the individual circumstances of the patient in terms of their disease-specific variables and their overall health. I think in terms of treatment options for men certainly under age 65 and perhaps even older, the risk-benefit ratio long term continues to favor surgical removal of the prostate."

Dr. See said that all of the treatment options for prostate cancer, including surgery, carry with them some risk. "You need to be careful about generalizations," he said, "because it's all in the details. One needs to be very cautious about sweeping statements about the best therapy.

"The best therapy, in truth, is one that's been tailored to the individual needs of the patient, in which they understand the pros and cons and have elected to proceed with that particular therapy based upon a clear and comprehensive understanding of what's involved."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.