Treatment or Observation for Localized Prostate Cancer

The treatment of prostate cancer is complicated. Prostate cancer is theoretically curable when it is localized (meaning confined to the prostate gland).

Treatment is with radical prostatectomy.

There are three groups of localized prostate cancer (prostate cancer cells that appear to be still confined to the prostate gland):

1. Apparently localized prostate cancer that has already spread to the rest of the body and so cannot be cured by a localized treatment like radical prostatectomy
2. Localized prostate cancer that is not growing at all or is growing so slowly that no treatment is needed.
3. Localized prostate cancer that has not yet spread to the rest of the body but that will if it is not removed from the body with a radical prostatectomy.

There are some apparently localized prostate cancers that have already spread to the rest  of the body and radical prostatectomy won’t prevent death from prostate cancer (that is, the patient will still die from prostate cancer despite the radical prostatectomy.) And death from prostate cancer that has already spread can occur many years after the radical prostatectomy

And there are many localized prostate cancers that  will grow slowly or not at all and so the patient would never die from that type of prostate cancer even if the patient never received any therapy. Patients in this group will live just as long without any therapy for their prostate cancer as if they had radical prostatectomy. They might actually live longer with no therapy as radical prostatectomy itself has many side effects.

There are a third group of localized prostate cancers. These are prostate cancers that have not spread to the rest of the body and yet will spread to the rest of the body if not removed by a radical prostatectomy. In these cases the prostate surgery will prevent a person from dying of prostate cancer.

Unfortunately, there is currently no way to tell which of the three groups a patient with apparently localized prostate cancer falls into.

A radical prostatectomy can only help patients in the third group.

So it is possible that, overall, a radical prostatectomy in patients with apparently localized prostate cancer won’t help those patients live longer or live better. And patients will suffer the dangers and side effects of radical prostatectomy (impotence, incontinence, infection, death from the surgery) without any benefit of longer or better lifespan.

A recent landmark study, “Radical Prostatectomy versus Observation for Localized Prostate Caner”, in the New England Journal of Medicine, concluded:

“Among men with localized prostate cancer detected during the early era of PSA testing did not significantly reduce all-cause or prostate-cancer, as compared with observation, through at least 12 years of follow-up. Absolute differences were less than 3 percentage points.” (1)

An analysis of the study is published in the same issue. (2) I feel somewhat uncomfortable with that analysis, which calls the study in to question on the basis of some technical issues. I look forward to other commentaries on this ground breaking study.

So what would I do if I were diagnosed with localized prostate cancer? I would seek consultation with a physician who is knowledgeable about all aspects of prostate cancer.

Right now I think I would consult with, perhaps, a knowledgeable medical oncologist. Since he does not perform radical prostatectomy he will not likely be biased for or against its performance.

If I had prostate cancer of the type in the study, at this time, I would chose not to have a radical prostatectomy,

(1) Radical Prostatectomy versus Observation for Localized Prostate Cancer, Wilt, TJ et al. NEJM July 19, 2012, vol 367, no 3.
Abstract available at
Full text is at

(2) Prostate Cancer—Uncertainty and a Way Forward, Thompson and Tagron, NEJM Judy 19, 2012, Vol 367, no.3.
Full Text available at

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