Tuesday, 1 May 2012

Surgery in the spotlight

A thorny debate, which has largely been confined to the world of clinical specialists and researchers, recently had a much more public airing. In his exclusive front page article in The Independent, Jeremy Laurance put the wrangle over how best to treat men with localised prostate cancer firmly in an open forum.

His article centred on the early findings of the on-going, and large-scale PIVOT trial, which is exploring how men with prostate cancer who opt for surgery to remove the gland fare in the survival stakes over a decade against those who choose to watch and wait. Preliminary findings, which have looked at 731 men, are both interesting – and a little unsettling. They suggest that taking the surgical route – which can entail some difficult side effects such as incontinence and erectile dysfunction – does not have any significant impact on how long a man with less aggressive forms of the disease will live.

Behind the scenes, surgeons and oncologists have been debating this very question for some time, with the latter suggesting surgery is over used – and not reached a consensus. It would be easy to conclude from these results that the ‘argument’ is over, but it is a little more complicated than this. The PSA blood test, the cornerstone of prostate cancer diagnosis, is unable to detect alone if a man has prostate cancer, let alone if he has an aggressive form of the disease. The development of MRI scans and other techniques means that doctors are becoming more equipped at recognising which tumours pose a real threat, but we are still not in a position where we can diagnose easily and early if a man has a so-called ‘tiger or pussy-cat’. As Jeremy Laurance rightly points out in his accompanying opinion piece, the focus now needs to be on increasing research into diagnostic tools equipped to identify which men with the most common cancer in the UK need more radical treatment. We also need explore more fully strategies like risk-based screening. Only then will we slash the risk of men being unnecessarily treated.

The fact that prostate cancer has been subject to a legacy of neglect is something which is often talked about, and is in danger of losing its impact. But this is a clear example of how under investment in this disease still means uncertainty when it comes to diagnosis and, ultimately, difficult decisions for men who are often in a position of weighing up treatment options. A quick glance at the well-oiled diagnostic route for breast cancer, which has had an extremely successful movement behind it pushing for advances which we need to emulate for men, shows how far behind prostate cancer is.

The other message is that these are early results, and practice in the UK has evolved since the trial began in 1994. Watchful waiting, which is the comparator to surgery in this study, is now only offered to men who are not healthy enough to have other treatments. Anyone diagnosed with low-risk early prostate cancer will be offered surgery, radiotherapy or active surveillance, which does not involve treatment but tumours are regularly monitored and only treated where necessary. A large study in the UK, the ProtecT trial, is looking to see which of these treatments is best, and will report in 2016.

Men about to undergo surgery will no doubt read these results with interest and some trepidation. Any decision around treatment needs informing with expert opinion, and we urge men to discuss their options and any concerns with their clinician. From what they tell us, many men opt for surgery as they simply want to remove the tumour – and any risk – from their body. This is why many develop a powerful bond with their surgeon. Until there is conclusive evidence otherwise, and until there is a better way of separating the aggressive and non-aggressive forms of the disease, surgery, despite its potential pitfalls and side-effects, will remain a valid option for many men.

Prostate cancer is, admittedly a complex disease and way too many men are facing complicated decisions without adequate support. However, its complexity does not mean we should ignore these or other research findings, or worse increase variation in practice. The clinical community has a responsibility to identify what ‘good treatment’ looks like, and it is critical that oncology and surgical teams work together for the benefit of men – not treat them as an interesting debate point.

Anyone wanting to discuss treatment options can call our confidential Helpline, which is staffed by specialist nurses, on 0800 074 8383.

2 comments:

  1. It would be interesting to see the data broken down by age at the point of treatment, and by Gleason score.

    For the moment I am with Ben Challacombe of Guy's who said "Many of the men in the trial were older, with an average age of 67, low risk and would not have been offered surgery in the UK".

    It's worth bearing in mind that in the UK 72 is typically the upper age for radical surgery, so a cohort with an average age of 67 almost certainly does not reflect a typical UK sample.

    To an extent surgery will always have an element of over-treatment as until the organ is removed no full pathology can take place. We know that the typical 10/12 needle biopsy can miss tumours, or that one needle will hit the only tumourous cells to be found.

    My own case is therefore interesting. Aged 50 (and thus very much younger that most in the PIVOT trial) I had nine of ten biopsy needles positive, and 70% average tumour cells in each positive needle.

    I opted for surgery (at Guy's as it happens, though with Rick Popert) and the post-op pathology showed a tumour in both lobes of my prostate 20mm long and 7mm in diameter in an organ that should only be 40mm in diameter.

    I'm therefore certain that for me radical surgery was the best option. I'll report back in ten, fifteen and twenty years time to let you know the results - to date I am only 18 months post-op.

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  2. A very interesting artical, I opted for Robotic Surgery at Addenbrooks and being given the all clear was a major releif. Not suffering any side effects was the icing on the cake.

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