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Men who opt for prostate cancer surgery -- especially when they're under age 65 -- are less likely to die of their disease than those who choose no treatment, Scandinavian researchers report in this week's New England Journal of Medicine.

The findings come on the heels of a US study published last week in the Journal of the American Medical Association that suggested some men can safely skip treatment -- a strategy known as watchful waiting.

Though the conclusions may seem contradictory, experts say they actually complement each other. The Scandinavian study compared two treatment options -- surgery or watchful waiting -- while the US study only looked at how men fared once they'd already chosen watchful waiting. Both offer information men can use when they make decisions about treatments.

"Any treatment decision is always based on many factors, including the age of the patient, the other medical conditions a patient may have, and what his life expectancy is," said Len Lichtenfeld, MD, deputy chief medical director of the American Cancer Society. "It's important to have a discussion with a doctor knowledgeable about prostate cancer before making a decision."

Prostate cancer is the most common cancer in US men, after skin cancer. This year alone, it is expected to strike more than 230,000 men, and kill around 30,000. Treatments for early-stage disease include surgery, radiation, or watchful waiting. But figuring out which treatment to choose can be difficult, especially for men with early-stage disease.

That's because some prostate cancers grow very slowly and never cause problems. Treating these cancers might not be necessary, and it could also lead to unwelcome side effects like impotence and incontinence.

Other prostate cancers, though, are aggressive and deadly. For men with these types of cancers, the benefits of treatment outweigh the risks of its side effects.

There's no ironclad way to tell for certain which type of cancer a man has, but there are some biological clues like PSA (prostate-specific antigen) levels and Gleason score (a measure of how abnormal -- and potentially aggressive -- the cancer cells are). Men with low marks in both these categories may have slow-growing cancers, and may be candidates for watchful waiting.

Last week's JAMA study, led by researchers at the University of Connecticut Health Center, showed that men with very low Gleason scores -- between 2 and 4 -- generally do well in the long term with watchful waiting.

The researchers studied the medical records of 767 men between the ages of 55 and 74 who had early-stage disease. All had been diagnosed in the 1970s and early 1980s and all had chosen watchful waiting instead of aggressive treatment. Those with Gleason scores under 4 were found to have very little risk of dying because of their prostate cancer, even 20 years after diagnosis. By contrast, men with the highest Gleason scores -- between 8 and 10 -- had a high risk of dying from prostate cancer.

The finding doesn't surprise Durado Brooks, MD, director of prostate and colorectal cancers for ACS.

Like many cancer doctors, Brooks already believed that men with high-grade tumors are more likely to die no matter what treatment they get. And conversely, those with low-grade tumors are less likely to die even if they get no treatment. The two studies add support to that belief.

The new Scandinavian study suggests, however, that certain men may be better off choosing surgery.

Researchers from the Scandinavian Prostate Cancer Study Group No. 4 studied 695 men under age 75 with early-stage prostate cancer. Half were randomly assigned to treatment with a surgery called radical prostatectomy, while the rest were assigned to watchful waiting. They were tracked for 10 years.

In that time, men who got surgery were less likely than men who had no treatment to have their cancer progress locally (19% vs. 44%) or spread to other parts of the body (15% vs. 25%). They were also less likely to die from prostate cancer (10% vs. 15%), but this difference was primarily seen among men under age 65.

Although the study didn't have the statistical power to say for certain that surgery is better for younger men, the data are suggestive, Brooks said.

"It is good to see a well-designed, decent-sized study that has long-range follow up that supports the concept that in some situations, prostatectomy can decrease the mortality and morbidity related to prostate cancer, considering how much the surgery is being done in this country," he said.

The two studies are unlikely to change the way doctors advise their patients about prostate cancer treatment, Brooks said.

"My suspicion is that there aren't a lot of men under 65 without [other medical problems] who are advised to watch and wait," he said. "Watch-and-wait men are usually those over 65 with [other medical problems] and low Gleason scores."

The first author of the US study agreed.

"The older men are the ones for watchful waiting," said Peter C. Albertsen, MD, MS, chief of urology at the University of Connecticut Health Center. "Younger men with high-grade disease should definitely go for [treatment]."

Older men with high-grade disease could also benefit from treatment, he said, but those decisions must always be made on a case by case basis.

Neither study dealt with the side effects of each treatment option, nor looked at men who chose radiation treatment for their prostate cancer. It's also not clear what effect PSA testing might have on prostate cancer outcomes. Because testing is becoming more common, prostate cancers are now being found even earlier than they were discovered in the men who took part in these studies.

Studies of the effect of screening and different treatment options are under way. Results are expected in the next few years.

Citations:
"Radical Prostatectomy versus Watchful Waiting in Early Prostate Cancer." Published in the New England Journal of Medicine (Vol. 352, No. 19: 1977-1984). First author: Anna Bill-Axelson, MD, University Hospital, Uppsala, Sweden.

"20-Year Outcomes Following Conservative Management of Clinically Localized Prostate Cancer." Published in Journal of the American Medical Association (Vol. 293, No. 17: 2095-2101). First author: Peter C. Albertsen, MD, MS, University of Connecticut Health Center.