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No treatment
for Prostate Cancer proven superior
Newswise — Patients who
undergo complete prostate removal are less
likely to experience urinary incontinence or
other complications if the operation is done
by an experienced surgeon in a hospital that
does many of the procedures, according to a
report funded by the Agency for Healthcare
Research and Quality, part of the U.S.
Department of Health and Human Services.
However, the new report
concludes that scientific evidence has not
established surgery or any other single
treatment as superior for all men.
The analysis compared the
effectiveness and risks of eight prostate
cancer treatments, ranging from prostate
removal to radioactive implants to no
treatment.
An article based on the
report is posted today in the online version
of the Annals of Internal Medicine.
“This report is a reminder
that patient outcomes may vary according to
treatment settings,” said AHRQ Director
Carolyn M. Clancy, M.D.
“But this analysis also
underscores a broader message: when it comes
to prostate cancer, we have much to learn
about which treatments work best, and
patients should be informed about the
benefits and harms of treatment options.”
The prostate gland, which
is about the size of a walnut, is located
just below the bladder. It makes and stores
the liquid that carries sperm. In 2007,
about 218,000 men were diagnosed with
prostate cancer, and about 27,050 men died
from the disease.
The primary goals of
treatment are to determine whether an
intervention is needed to prevent death and
disability and to minimize complications.
Treatment choices often take into account a
patient’s age, race, ethnicity, health
status, family history, patient preferences
and how quickly the cancer is likely to
spread.
The lifetime risk of being
diagnosed with prostate cancer has nearly
doubled to 20 percent since the late 1980s,
due mostly to expanded use of the Prostate
Specific Antigen (PSA) blood test.
But the risk of dying of
prostate cancer remains about 3 percent.
Therefore, considerable overdetection and
overtreatment may exist. The U.S. Preventive
Services Task Force, a panel of outside
experts convened by AHRQ that makes
independent evidence-based recommendations,
maintains there is insufficient evidence to
recommend for or against PSA testing for
routine prostate cancer screening.
PSA tests can detect
early-stage cancer when it is potentially
most treatable but also lead to frequent
false-positive results and identification of
prostate cancers unlikely to cause harm.
AHRQ’s new report, based
on a review of 592 published articles,
compared eight prostate cancer strategies:
complete surgical removal of prostate and
related tissue; minimally invasive surgery
to remove the prostate; external radiation;
radioactive implants; destruction of cancer
cells through rapid freezing and thawing;
removal of testicles or hormone therapy;
high-intensity ultrasound; and no immediate
treatment, also known as “watchful waiting.”
The report, compiled by
AHRQ’s Minnesota Evidence-based Practice
Center, is intended to provide unbiased,
evidence-based information so that patients,
clinicians and others can make the best
treatment decisions possible. Among its
conclusions:
• Not enough scientific
evidence exists to identify any prostate
cancer treatment as most effective for all
men, especially those whose cancers were
found by PSA testing. However, more than 90
percent of patients reported they would make
the same treatment decision again,
regardless of the treatment they received.
• All treatment options
cause health problems, primarily urinary
incontinence, bowel problems and erectile
dysfunction. The chances of bowel problems
or sexual dysfunction are similar for
surgery and external radiation. Leaking of
urine is at least six times more likely
among surgery patients than those treated by
external radiation.
• One study showed that
men who choose surgery over watchful waiting
are less likely to die or have their cancer
spread. The benefit appears to be limited to
men under 65. However, because few patients
in this study had cancer detected through
PSA tests, it is unknown if this finding
would apply to those whose cancers were
detected through PSA screening. Another
smaller study showed no difference in
survival between surgery and watchful
waiting.
• Among patients who
choose surgery, urinary complications and
incontinence are less likely if their
surgeons performed more than 40 prostate
removals per year.
• Surgery-related deaths,
urinary complications and readmissions were
lower and hospital stays were shorter in
hospitals that performed more prostate
removals.
• A lack of research makes
it impossible to compare several treatments:
rapid freezing and thawing (cryotherapy);
minimally invasive surgery (laparoscopic or
robotic assisted radical prostatectomy);
testicle removal or hormone therapy
(androgen deprivation therapy); and
high-intensity ultrasound or radiation
therapy.
• Adding hormone therapy
prior to prostate removal does not improve
survival or decrease recurrence rates, but
it does increase the chance of adverse
events.
• Combining radiation with
hormone therapy may decrease mortality. But
compared with radiation treatment alone, the
combination increases the chances of
impotence and abnormal breast development.
The report released today,
Comparative Effectiveness of Therapies for
Clinically Localized Prostate Cancer, is the
newest analysis from AHRQ's Effective Health
Care program.
This AHRQ program
represents an important federal effort to
compare treatments for significant health
conditions and make the findings public.
The Effective Health
Care program also translates reports into
plain-language guides for clinicians,
patients and policymakers. Information on
the program, including full reports and
summary guides, can be found at
http://www.effectivehealthcare.ahrq.gov
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