Men who have their prostate glands removed to treat localized prostate cancer are about half as likely to die of the disease in the next six years, compared to those who put off treatment until symptoms occur, according to a report in the Sept. 12 New England Journal of Medicine (Vol. 347, No. 11: 781-789).

"This study gives men a much better underpinning for a rational discussion with their doctors about what they should do," said the study's lead author, Lars Holmberg, MD, of the University Hospital in Uppsala, Sweden.

But whether surgery or another option is best for an individual man depends on his age, general health, and other factors, said Holmberg.

This study randomly divided 695 men with prostate cancer into two groups. Half were treated with surgery called radical prostatectomy, or RP, and half were followed until symptoms occurred, called watchful waiting. All had early-stage tumors of a similar grade.

Radical prostatectomy and radiation therapy are commonly used to treat early prostate cancer. But because this cancer usually grows so slowly, there has been a lot of debate over whether treating right away is better than waiting until symptoms appear.

Many older men will likely die of other causes before the cancer causes problems, while the possible side effects of surgery or radiation therapy (including urinary and sexual problems) can affect men’s quality of life.

Until now, doctors weren't sure radical prostatectomy would lessen men's chances of dying of prostate cancer compared to watchful waiting.

During an average of about six years of follow-up, 31 of the men in the watchful waiting group died of prostate cancer, compared to 16 of the men treated with RP.

Spread of the disease to distant organs was about one-third less likely among RP patients.

In a quality of life study in the same issue of the journal (790-796), Holmberg and others found that difficulty with impotence and controlling urination was reported about twice as often among RP patients as among watchful waiting patients, while watchful waiting patients were about 50% more likely to have a weak urinary stream.

There was little difference between the groups in how much difficulty they had with bowel function, anxiety, or depression.

"The quality of life study can help men decide what they want to do when dealing with this disease," said Holmberg.

In an editorial in the same journal (839-840), prostate cancer surgeon Patrick C. Walsh, MD, of Johns Hopkins Hospital in Baltimore, pointed out that surgery, radiation therapy, and watchful waiting all have a place in treating some cases of the disease.

RP is an excellent option for a young man who is healthy except for his prostate cancer. For an older patient or a man with one or more other serious medical conditions in addition to prostate cancer, radiation therapy may be best. Many men fall in between these groups, and can reasonably consider either therapy, Walsh said.

And watchful waiting will likely always be the best option, he added, in men who are unlikely to survive longer than 10 years, either due to advanced age or another illness.

With regard to the study, Walsh noted that over time, surgery's ability to reduce distant spread may increase its demonstrated advantage, since distant spread usually is fatal in a few years.

Until ongoing studies comparing survival after surgery or radiotherapy for localized prostate cancer are completed, doctors should fully inform men with prostate cancer about the different options they have and help them choose the best doctor to treat them with the method they choose, said Walsh.

According to Durado Brooks, MD, MPH, director of prostate and colorectal cancer control for the American Cancer Society, although fewer RP patients in the study died of prostate cancer, they had more deaths from other causes, so there was no overall survival advantage.

The similarity in overall quality of life both groups reported was likely because watchful waiting patients were satisfied with not having to have treatment, and RP patients accepted the expected sexual function problems, said Brooks.

These problems may be less of an issue in the future. In many US medical centers today, nerve-sparing surgery is available that may not damage the nerves responsible for erections, Brooks said.

"These two studies taken together show how very important it is for prostate cancer patients to fully discuss these issues with their doctor before deciding how to proceed in regard to this disease," said Brooks.