Doctors Disagree on Optimal Treatment for Prostate Cancer

There is simply no “best” way to treat prostate cancer, the most common type of cancer in American men. This disconcerting truth became evident in a recent New England Journal of Medicine Web-based poll of readers (mostly physicians) invited to weigh in on treatment of a hypothetical prostate cancer patient. The treatment advice was almost evenly split among three common prostate cancer treatment options — expectant management, radiotherapy and radical prostatectomy. The lack of consensus underscores how important it is for men diagnosed with prostate cancer to make informed treatment decisions that are right for them.

The case vignette appeared in the December 11, 2008, issue of the New England Journal of Medicine (NEJM) in Clinical Decisions, an interactive feature that presents a case for which there may be more than one appropriate treatment, followed by several treatment options presented by experts in the field. Readers are invited to “vote” for and comment upon a treatment option. For the prostate cancer case vignette, the New England Journal of Medicine described a hypothetical 63-year-old patient who was otherwise healthy, with normal sexual function and no symptoms. His PSA was tested three times, rising from 1.5 ng/mL to 3.1 ng/mL after one year, and to 3.8 ng/mL a year later. (A PSA level of 3.8 ng/mL can be an indication for a biopsy.) While the digital rectal exam (DRE) was normal, two out of 12 core biopsies of his prostate showed a moderate risk of cancer.

Among the 3,720 votes cast by readers, approximately 29% were for expectant management, 33% were for radiotherapy and 39% were for radical prostatectomy. An article describing the polling results was published in the January 15, 2009, issue of the New England Journal of Medicine.

Following are the descriptions of each treatment approach and a sampling of voters’ comments:

Expectant management (also known as active surveillance or watchful waiting) involves closely monitoring the patient with frequent testing (PSA, DRE and biopsies) but without active treatment. This option is ideal for men who have early stage, slow-growing cancer confined to the prostate and for men who may not be able to undergo treatment due to other health conditions. It may be a good option for older men considered unlikely to benefit from aggressive therapies such as radiotherapy and surgery. The benefit of expectant management is avoiding the complications associated with surgery and radiation, including incontinence and impotence, that many find worse than the disease. Of course, there is a potential downside too — the cancer may progress to a more advanced stage, at which point a patient may wish he had pursued earlier treatment. Several voters for expectant management emphasized the low risk involved in watching and waiting. Others wanted to wait to see if the patient’s PSA levels would continue to rise, and at what rate, with testing every few months — they also emphasized close monitoring.

Radiotherapy is a form of radiation therapy (brachytherapy) in which radioactive seeds are implanted directly into the prostate under the guidance of transrectal ultrasonography. This option may be recommended for men with early-stage prostate cancer or those unable to choose surgery because of their age or other health conditions. While it can cause impotence and incontinence, voters in favor of radiotherapy said it was associated with fewer complications and a faster recovery time than radical prostatectomy.

Radical prostatectomy is the surgical removal of the entire prostate (including some of the tissue around it) and the seminal vesicles. It is recommended for men who are in good health with early-stage cancer that is confined to the prostate — but with this approach, too, the potential side effects include urinary incontinence and impotence. Voters in favor cited the patient’s young age, his good health and life expectancy. Many believed surgery offered the best chance for a cure.


The polling results came as no surprise to J. Stephen Jones, MD, the chairman of the department of regional urology at the Cleveland Clinic Glickman Urological and Kidney Institute. “Cases like this are very common, and they present a challenge for physicians because there is no right answer,” he said. “From a scientific standpoint, you could justify any of these treatment approaches, or you could justify doing nothing at all.”

Dr. Jones is referring to the lack of randomized, controlled studies that demonstrate that one prostate cancer treatment is more effective than the others. Last year, the Agency for Healthcare Research and Quality, a division of the US Department of Health and Human Services, conducted a review of 592 published articles comparing the effectiveness and risks of eight different prostate cancer strategies (including surgery, external radiation, radioactive implants, hormone therapy and watchful waiting) and concluded that “not enough scientific evidence exists” to recommend any single treatment as “most effective for all men.”

Dr. Jones told me that a key reason for the dearth of definitive findings is that prostate cancer is a slowly developing disease, often taking 10 to 20 years to turn deadly. “It’s hard to follow patients for 20 years or more,” he said. “As a result, no study has ever successfully been able to prove that any of these treatment approaches is better than the others.”