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Tough Treatment Decisions: The Example of Prostate Cancer

Timothy B. McCall, M.D.

Prostate cancer is the most common cancer among American men. When we read about the deaths of men in the prime of their careers, such as the musician and composer Frank Zappa, it’s natural to feel that aggressive therapy is called for. In reality, the decision whether to treat prostate cancer is a very personal one, fraught with uncertainty. Consider the following:

• At the time prostate cancer is diagnosed, most men have no symptoms. At diagnosis, most men have localized tumors, that is, confined to the prostate gland. Since they have no symptoms, the goal of treatment is to prevent or to delay spread of the cancer to other parts of the body.
• Most men with prostate cancer never get symptoms. Since prostate cancer often affects older men, many of them will die from other causes before the prostate cancer gives them any problems. When autopsies are done on 80 year old men who die of unrelated causes, small areas of prostate cancer are found in most of them.
• Treatment for prostate cancer has never been proven effective. Treatment with either surgery or radiation therapy theoretically reduces the likelihood of the cancer spreading to other parts of the body but the theory has never been proven. We simply do not know whether radical prostate surgery or radiation therapy will increase life expectancy—although many doctors believe that they do. It will be years until studies currently underway will give us the answer. For the majority of men who were never destined to get symptoms, treatment definitely decreases their life expectancy and the quality of their lives.
• Any benefit of treating localized prostate cancer may not be realized for years. When prostate cancer is treated, doctors are betting that by preventing the later spread of the cancer they can add years onto the end of their patients’ lives. Many men die of other causes before they ever have a chance to realize this benefit. Many develop other conditions like Alzheimer’s disease or debilitating heart conditions that lower the quality of the extra years provided by the prostate cancer treatment.
  In other words, when you treat prostate cancer you trade an immediate risk for the possibility of gain later on. Some men are unwilling to give up several more years of good quality life for the possibility of adding time of uncertain quality on to the end of their life. Experts believe that men over 75 are unlikely to live long enough to realize the benefits treatment.
• The complications of treatment begin immediately. Prostate cancer tends to grow slowly. If prostate cancer is going to spread to other parts of the body, it often does so years later. According to the Journal of the American Medical Association, the average time until the cancer spreads is 14 years.

Prostate cancer surgery, the so-called radical prostatectomy, is a major operation with a significant recovery period and serious potential side effects. Impotence and incontinence are common. In a recent survey of men two to four years after the operation, only 11 percent reported any erections sufficient for intercourse in the prior month. Radiation therapy also has significant side effects, although usually less severe than surgery’s. Major complications in the first month after surgery, like a heart attack or blood clot in the lung, strike 7 percent of men over 75 and 10 percent of men over 80. For men over 75, one in 71 dies within one month of the operation. For men over 80, one in 22 is dead within a month.

Treatment may improve life expectancy but diminish the quality of that life. Consider a study from the Journal of the American Medical Association that analyzed the advantages and disadvantages of treating localized prostate cancer. Ignoring quality and looking only at life expectancy, the researchers found that treatment provides some benefit to men under 70. But when quality of life was factored in, they concluded that the benefits of treatment are modest.

The study found that even though treatment is more effective for less malignant tumors, because these tumors are less likely to spread, the benefits of treatment are less likely to offset the impact of complications, like impotence or incontinence, on the quality of life. For men with less malignant tumors, treatment offers little advantage over watchful waiting. On the other hand, even though treatment is less effective for more malignant tumors, these tumors tend to spread and treatment is more likely to benefit the patient.

Putting all of this together and making the best choice can be difficult. Since medical experts disagree about the best approach, I advise anyone diagnosed with prostate cancer get as much information as possible and weigh it in light of what is most important for you. And remember most cancers have been there 10 or more years before they are detected. There is little to be lost by waiting a few weeks to do some research and make the right choice.

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