The news of a prostate cancer diagnosis is often shocking and frequently comes as a surprise…the idea of a tumour developing within your body is unsettling.
Men typically find themselves confronted with a treatment decision almost immediately, and many instinctively lean towards surgery to remove the tumour. Given my 15 years of experience as an oncologist specializing in this condition, you might think I would support this approach.
However, I advise patients to pause before making any quick decisions. Increasing evidence suggests that surgery isn’t always the most effective treatment available.
Nearly all men who choose to have their prostate removed will experience complications, ranging from mild incontinence to the more severe and permanent erectile dysfunction that affects about half of them.
If the operation guaranteed to save lives, the potential risks could be justified, but we now understand that for many men, their cancer grows so slowly that it may never advance, and there are viable alternative treatments.
SURGERY DOES NOT IMPROVE SURVIVAL
The Prostate Intervention Versus Observation Trial (PIVOT), which began in 1994, included 731 men averaging 68 years old who had been diagnosed with prostate cancer.
Half of the participants chose to undergo a surgery known as ‘radical prostatectomy’, while the other half opted for ‘watchful waiting,’ meaning they did not receive immediate treatment.
Instead, these men started hormone therapy only when symptoms such as urination difficulties began to arise. The findings indicated that, on average, those who had surgery were no more likely to survive compared to those in the watchful waiting group.
In the trial, only seven percent died from prostate cancer, in contrast to 41 percent who passed away from unrelated health issues.
So, who is a candidate for surgery? Well-known figures facing this diagnosis, like Hollywood’s Robert De Niro and Nelson Mandela, have chosen to undergo surgery. Nevertheless, not every one of the 30,000 Australian men diagnosed yearly should follow suit.
BUT THERE ARE EXCEPTIONS
Often, men with prostate cancer display no symptoms whatsoever. Typically, the diagnosis arises from prostate-specific antigen (PSA) testing, which detects a protein produced in increased amounts by the prostate when a tumour is present.
A digital rectal examination is conducted to assess whether the prostate’s surface has an irregular texture.
If elevated PSA levels or changes in the prostate’s surface are noted, a biopsy is done by extracting tissue from the prostate using a needle.
The cancerous cells are then examined microscopically, and a Gleason score is calculated—the lower the score, the less likely the cancer is to spread.
When results indicate a PSA score above 20 or a Gleason score between 8 and 10, immediate treatment is typically recommended.
One key insight from PIVOT is how significantly surgery seems to benefit those with high-risk cancer.
ACTIVE SURVEILLANCE MAY BE THE BEST OPTION
For men diagnosed with a PSA score below 10 and a Gleason score of 6, I usually would not recommend surgery. Instead, active surveillance is a preferable approach, serving as a balance between watchful waiting and surgical intervention.
During active surveillance, the patient undergoes regular assessments, including MRI scans, blood tests, and biopsies, to keep track of the cancer’s status. If there are signs of progression, treatment options are evaluated, which do not automatically include surgery.
Instead, one might consider radiotherapy, brachytherapy (internal radiotherapy involving the placement of small radioactive metal seeds within the tumor), and ultrasound treatment.
For those who are very elderly or have other significant medical issues, watchful waiting remains a viable option.
THE PSYCHOLOGICAL HURDLE
It’s crucial for a man diagnosed with low-risk prostate cancer to navigate the psychological challenge of having cancer within his body.
In fact, numerous specialists argue that a Gleason 6 prostate tumor should not even be classified as ‘cancer’ since it is vastly different from more aggressive forms—like brain tumors—that typically come to mind with the term ‘cancer.’
Regardless of whether your cancer is low or high-risk, consistent communication should occur between yourself, your doctor, oncologist, and urologist.
Do not let the overwhelming amount of information provided about the condition deter you. Take the necessary time to contemplate the available options, as opting to remove the prostate represents a significant life-altering decision.
by David Livingstone
