What should men do if the doctor says, “You have prostate cancer”? This is a difficult question to answer because doctors cannot agree on the right treatment. Now, a report in The New England Journal of Medicine challenges the benefits of surgery. Its basic message to doctors is to follow the first principle of medicine, “First, do no harm”.
The lifetime risk for men of developing prostate cancer is about 16%, and the risk of dying from it only 3%. This indicates that many prostate cancers are not dangerous and that no treatment is the prudent option.
The U.S. study involved 731 males with localized prostate cancer who were given the option of either surgery or watchful waiting. They were then followed an average of 10 years. The study concluded there was no statistical difference in the risk of death between these two groups. Other studies have reached the same conclusion.
But statistics never tell the whole story. Professor Fuller Albright, one of Harvard’s brilliant researchers, once remarked to my class, “If you have to prove something by statistics, it’s usually wrong”. So in the end, whether or not to treat prostate cancer is a decision that can only be made by the patient and his doctor.
This study confirmed what I’ve always believed about prostate surgery. Patients must be prepared to accept the risk of surgical complications. Over the years I’ve received more negative feedback from readers about prostate surgery than any other procedure.
Improved surgical technique has diminished the risk of complications of prostate operations, but this study, lead by a Minneapolis researcher, shows that 21% of patients suffered post-surgical complication during the first 30 days.
The major complications are impotence and urinary incontinence. Sometimes impotence can be helped by medication, but urinary incontinence is not so easily managed. As more than one patient has said to me, “I did not expect to live in diapers”. Others would never have agreed to surgery if this complication had been fully discussed earlier.
I also believe that urinary incontinence is an under-reported complication. The patient who is wetting his pants is always more aware of the problem than the doctor who did the operation!
What has caused this debate is the increased use of the PSA test. In fact, Richard Albin, the discoverer, wished he had never developed it as it’s resulted in a public health disaster. He admits it’s an imperfect test resulting in too many early malignancies being discovered for which treatment may not be required. Albin has never had a PSA test himself, and for the record, neither have I.
The great problem is that no one likes to know they’re living with malignancy. I repeatedly urged a 70-year-old friend and patient who had a microscopic area of prostate cancer not to have surgery. He had the operation and died of a complication. It’s well to remember that one in three men at age 40 shows evidence of microscopic prostate cancer and 50% at age 80.
So this is a disease where it’s often better to live with the devil you know than the one you don’t know. Prostate cancer, particularly as you grow older, is a bit like getting gray hair. Neither problem is going to kill you.
I’ve always remembered what Dr. Willett Whitmore told me many years ago during an interview in New York City. Whitmore, a world authority on prostate cancer, remarked, “Getting older is invariably fatal, cancer of the prostate only sometimes”.
Whitmore added that the survival rate had little to do with the treatment. Rather, it was related to the “biological nature of the cancer”. In effect, was it a slow or rapidly growing malignancy? Currently it’s hard to determine this.
So patients and doctors continue to need the Wisdom of Solomon to treat this disease. But this and other studies show that many men would be wise to choose no treatment, the only way to do no harm. The final decision, however, must rest with you and your own doctor.
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