Long Island Business News
March 18, 2014
Surgeons Divided by Prostate Cancer Debate
Featuring: Dr. Louis Potters, Chair, Radiation Medicine, North Shore-LIJ Health System &
Dr. David Samadi, Chair, Urology, and Chief, Robotic Surgery, Lenox Hill Hospital
With a new prostate cancer study reporting that the “watchful waiting” strategy – operating only after cancer spreads – generally increases risks, the debate over prostate cancer treatments is flaring again.
The study of nearly 700 men, done in Sweden and published in the March 6 edition of the New England Journal of Medicine, divided subjects diagnosed with prostate cancer into two groups: One was observed only, until it showed symptoms. The other underwent surgery as soon as the first trace of cancer was detected.
The study concluded that “radical prostatectomy reduces mortality among men with localized prostate cancer.”
That conclusion is supported by surgeons who believe in eradicating cancers as soon as they’re found. But some surgeons argue that early surgeries often lead to unnecessary operations and serious side effects – and question the veracity of the study in general.
Dr. David Samadi, chairman of urology and chief of robotic surgery at Lenox Hill Hospital, part of the North Shore-Long Island Jewish Health System, said the study proves the dangers of “watchful waiting.”
“This study’s findings are not simply about prostate cancer treatment being effective,” Samadi said. “They specifically point to the efficacy of the prostatectomy in improving long-term survival and quality of life.”
Others interpret the survey differently, claiming the conclusions don’t confirm that delaying surgery is the wrong move – or that earlier surgery is always the right choice.
All the survey shows, according to Dr. Louis Potters, chairman of radiation medicine for the North Shore-LIJ Health System, is that “doing something versus nothing is better.”
“They found when you do nothing against doing something, patients do worse,” Potters said.
But comparing early surgery to “doing nothing” misses the point, according to some specialists, since other means of treatment can also be effective.
“This study didn’t look at radiation, which is actually the most commonly used treatment in this country,” noted Dr. Shawn Zimberg, medical director of radiation oncology at New Hyde Park-based Advanced Radiation Centers of New York. “The point of it is that treatment is better than no treatment.”
Further supporting that middle ground hypothesis, Potters noted, is that even “doing nothing” isn’t really doing nothing. “Watchful waiting” is more akin to “active surveillance,” he said, with doctors carefully monitoring cancer and taking immediate action at the first sign of progression.
Comparing no action to too-aggressive action, Potters added, is simply measuring two extremes, a fatal flaw in the Swiss study.
“They didn’t prove that surgery is better than active surveillance, or that surgery is the way that patients should be treated,” he said.
Another problem with the study, according to some U.S. doctors: It primarily reviewed patients with advanced cancers, rather than considering a full range of patients with less-advanced cancers.
Nearly 90 percent of those in the study were diagnosed through digital exams, meaning they displayed symptoms; all told, about 95 percent of men diagnosed with prostate cancer today are diagnosed based on prostate-specific antigen levels, with only 5 percent manifesting the kinds of symptoms detected in digital exams.
That disqualifies the survey from being a useful review of prostate-cancer treatments, according to Potters, who noted that up to 40 percent of men diagnosed with prostate cancer have what he called “meaningless” indicators, meaning it’s too early to tell whether the cancer will advance, or how.
“Generally speaking, patients with palpable disease are not candidates for active surveillance,” he said. “The bottom line is 88 percent of the men in this study would not be candidates for active surveillance, just based on the clinical extent of disease.”
The U.S. Preventive Task Force, a panel of healthcare experts that evaluates scientific evidence on clinical preventive services, has recommended against PSA screening based on data suggesting screening for prostate cancer doesn’t decrease mortality rates. Simply telling someone they have “cancer” can prompt them to seek aggressive surgery, the thinking goes, even if the cancer is so slight that it’s possible it won’t spread.
“The word ‘cancer’ can be a polluting word,” Potters said. “Once you say the word, it creates a fog. There is discussion that some of these low-risk cancers of the prostate should be called something different than ‘cancer.’”
Some prefer calling early traces “pre-cancerous” or “hyperplasia,” so patients can distinguish the lower risks from the forbidding presence of an aggressive disease.
“Sometimes cancers go away on their own,” Potters noted. “I have patients I’ve had on active surveillance. We re-biopsy them and their biopsy’s negative.”
Samadi – who acknowledged “each type of treatment, from robotic prostate surgery to radiation therapy, carries with it some side effects” – insisted that even monitoring a disease can be stressful. He cited frequent follow-ups and multiple biopsies, resulting in “both physical and emotional strain.”
But while Samadi clearly advocates for the aggressive-surgery approach, others argue surgery should be a last resort-type option when less-invasive options prove ineffective.
“I may repeat their biopsy every year or every two years,” Potter said. “If there’s any change to suggest that the disease is active, I will treat the patient.”