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Consumer Reports Insights: Treatment options for men with prostate cancer

Monday, January 3, 2011; 11:11 PM

Every year, nearly 218,000 U.S. men learn they have prostate cancer. The condition is usually diagnosed early, when it's most treatable, and better detection and treatment have decreased the death rate. But patients and their doctors need to decide how aggressively to treat the early-stage cancer.

Most prostate cancers are so unaggressive that one option is to simply monitor the tumor and start treatment if it progresses. But in a study of 124,000 men published last year in the Archives of Internal Medicine, three of four of those with early-stage cancer chose radiation or surgery, both of which can cause impotence, incontinence or both.

Patients often choose aggressive treatments for good reasons, including reassurance. But incomplete, confusing or in some cases biased information from their doctors also influences their decision.

First, get informed. Few medical decisions are as tough as those facing a man with prostate cancer. There's no shortage of treatments, including surgery performed with or without robotic assistance, and radiation delivered by an external beam or by radioactive seeds implanted inside the body.

But it's hard to compare safety and effectiveness. And because experts say that most prostate cancers are extremely slow-growing and might not pose a serious threat, many men might be better off deferring treatment.

Know your risk

To guide your decision, it's important to understand whether you have a low-, medium- or high-risk tumor. Risk is typically based on three factors: levels of prostate-specific antigen (PSA) in your blood, the size and extent of the tumor, and a rating of the tumor pathology called the Gleason score.

Small tumors that are confined to the prostate gland combined with low PSA levels (10 nanograms per milliliter or less) and low Gleason scores (six or lower) indicate a low-risk tumor that can make watchful waiting, also called active surveillance, a reasonable choice. If you have a medium- or high-risk tumor, treatment might be more appropriate - if you understand and accept the likely adverse effects of both radiation and surgery.

Robotic surgery provides no guarantee of fewer complications. And marketing hype might fuel unreasonable expectations. In a Duke University study, dissatisfaction was three to four times higher among those treated by robot-assisted surgery than among those treated by traditional surgery, even though rates of troublesome side effects were about the same.

Treatment options

Watchful waiting

(active surveillance)

l 10-year cancer death rate: About 3 percent for low-risk tumors; about 5 percent for intermediate-risk tumors

l Long-term adverse effects: Anxiety from uncertain cancer status

l Treatment description and common results: PSA testing two to three times a year and prostate biopsies once a year; half to two-thirds of patients can expect at least five years without need for treatment

l Good candidates: Men with low-risk tumors who highly value sexual activity and freedom from treatment side effects; men with a life expectancy of 10 years or less

Surgical removal

(prostatectomy)

l 10-year cancer death rate: Less than 1 percent for low-risk tumors; about 3 percent for intermediate-risk tumors

l Long-term adverse effects: Poor sexual function (53 percent); urinary leakage more than once a day (14 percent); frequent, urgent, bloody or painful bowel movements (1 percent)

l Treatment description and common results: Requires one to three days in a hospital and a week or two with a urinary catheter; removal of gland means less chance of recurrence

l Good candidates: Otherwise healthy men who have the longest life expectancy and the least surgical risk

External-beam radiation

l 10-year cancer death rate: About 2 percent for low-risk tumors; about 4 percent for intermediate-risk tumors

l Long-term adverse effects: Poor sexual function (58 percent); urinary leakage (7 percent); frequent, urgent, bloody or painful bowel movements (11 percent)

l Treatment description and common results: Requires seven to eight weeks of daily treatments; because the prostate isn't removed, lingering cancer cells may prompt recurrence; sexual problems tend to worsen over time

l Good candidates: Men who want to avoid major surgery or whose poor health or advanced age makes surgery too risky

Internal-seed radiation

(brachytherapy)

l 10-year cancer death rate: Long-term data not available; potentially similar to external-beam radiation

l Long-term adverse effects: Poor sexual function (46 percent); urinary leakage (10 percent); frequent, urgent, bloody or painful bowel movements (8 percent)

l Treatment description and common results: Requires one outpatient operation in which doctors implant radioactive seeds in the prostate; because the prostate isn't removed, lingering cancer cells may prompt recurrence; sexual problems tend to worsen over time

l Good candidates: Same as for external radiation but more practical for those who can't easily make daily trips to the hospital

(c) Copyright 2010. Consumers Union of United States Inc.

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