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Treatment vs. Observation in Older Men with Localized Prostate Cancer

Observational data suggest that treatment is associated with better survival.

Only one published randomized trial has compared radical prostatectomy and watchful waiting in men with early prostate cancer (Journal Watch May 20 2005); it showed a small survival benefit in the surgery group, but the benefit was confined largely to men under age 65, and most of the tumors were palpable (i.e., not detected by prostate-specific antigen [PSA] screening). While we await results of additional trials, researchers used observational cohort data from a Medicare cancer registry to assess the different approaches.

Of 44,630 men (age range, 65–80) diagnosed with localized, well- or moderately differentiated prostate cancer who were followed for up to 12 years, 28% were observed, and 72% received prostatectomy or radiation. There were 12,302 deaths, of which 926 (7.5%) were attributable to prostate cancer. In analyses adjusted for tumor size, tumor grade, and comorbidity, patients receiving active treatment were significantly less likely to die than those who were observed (hazard ratio, 0.69).

Comment: Despite statistical adjustment, this analysis of observational data might overestimate the benefit of treatment, because patients who receive treatment are generally healthier and are expected to live longer. Editorialists note that, of the total study sample, only 2.1% died of prostate cancer. For the most part, older men with localized prostate cancer still die with the disease, not because of it. Until we have more results from randomized trials, clinicians need to help older men with localized prostate cancer make treatment decisions according to health status, functional outcomes, and personal preference.

— Thomas L. Schwenk, MD

Published in Journal Watch General Medicine December 12, 2006

Citation(s):

Wong Y-N et al. Survival associated with treatment vs observation of localized prostate cancer in elderly men. JAMA 2006 Dec 13; 296:2683-93.

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• Medline abstract (Free)

Litwin MS and Miller DC. Treating older men with prostate cancer: Survival (or selection) of the fittest? JAMA 2006 Dec 13; 296:2733-4.

• Original article (Subscription may be required)
• Medline abstract (Free)