Regular monitoring of men with localised prostate cancer offers them the same – higher than expected – survival chance after 10 years as surgery or radiotherapy, according to a major study.
The trial, the largest of its type, looked at men diagnosed with the low-risk form of the disease through a PSA (prostate-specific antigen) test and found the survival rate for all three main treatment options was 99%, compared with the 90% researchers expected.
Having surgery to remove the prostate gland – a prostatectomy – or radiotherapy halved the risk of cancer progression, compared with monitoring, to around 10%, but caused more unpleasant side-effects.
The experts behind the study, funded by the National Institute for Health Research (NIHR) and published in the New England Journal of Medicine on Wednesday, said it has significant implications for up to 30,000 men diagnosed with localised prostate cancer via a PSA test each year.
Chief investigator Prof Freddie Hamdy, from the University of Oxford, said: “The doctor will be able to say your risk of dying of prostate cancer within 10 years is very low. If you do have [radical] treatment, it does improve [the chances the disease will not spread] but you have those side-effects. The conversation now between doctors and patients will be much better informed than in the past and will have less bias than before.”
He said clinicians had a tendency to recommend the treatment they offer personally but hoped the study would change that.
For the ProtecT trial, led by researchers at the universities of Oxford and Bristol in nine UK centres, 82,429 men across the UK aged 50-69 were tested and 1,643 diagnosed with localised prostate cancer agreed to be randomised to active monitoring (545), radical prostatectomy (553) or radical radiotherapy (545) between 1999 and 2009. The research team measured mortality rates at 10 years, cancer progression and spread, and the impact of treatments reported by men.
Approximately 50% of men under active surveillance, which includes regular PSA tests, had surgery or radiotherapy later in the trial monitoring period because of fear the disease was progressing.
The researchers said a longer-term follow-up was needed to see whether reducing the spread of prostate cancer through radical treatment boosted longevity and/or quality of life.
Prostatectomy had the greatest negative effect on sexual function and urinary incontinence, and radiotherapy caused more bowel problems, although the number of men experiencing side-effects declined over time.
The researchers stressed they were not recommending a particular course of action for men with a positive PSA test.
Co-investigator Prof David Neal, from the universities of Oxford and Cambridge, said: “Clinicians don’t necessarily have the right answer. It’s important there’s a genuine partnership so men can really understand what the benefits and disbenefits are so they can take the right decision for them as an individual.”
Anne Mackie, director at Public Health England Screening, said the study provided “key information needed to manage localised prostate cancer”.
Prostate cancer is the most common cancer in men, with about 47,000 diagnoses and 10,000 deaths every year in the UK.
But there is currently no national screening programme because of issues with the accuracy of PSA tests and their potentially harmful consequences. However, the advantage is that they may catch the cancer early.
Dr Matthew Hobbs, deputy director of research at Prostate Cancer UK, said the results were good news for men diagnosed with the localised form of the disease, adding: “Many men decide against active surveillance because of the uncertainty about the impact of that choice and the anxiety it causes.”
He said more work was needed to ensure cancers are found at an early stage, pointing out that only 22% of men diagnosed when it has spread outside the prostate and abdomen survive for 10 years.
Monitoring of prostate cancer as effective as treatment in some cases
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