Prostate Surgery - Spare The Knife, Keep The Rod

Who will tell the men?

That’s what I wondered last week when I read the abstract about prostate cancer patients’ grim prognosis for normal sexual activity after surgery or radiation for their disease. The study appeared in the Journal of the American Medical Association. Tara Parker-Pope in the New York Times’ Well blog gave it a shot today, and led with an anecdote about a surgeon who blithely told one patient that 98% of his robotic surgeries turned out fine. Not exactly.

An accompanying editorial in JAMA distilled down the odds for a 60-year-old, overweight man who reported some sexual dysfunction prior to surgery. Such a person would have just a one in three chance of remaining sexually active after a nerve-sparing operation. His odds would be only one in seven if the nerves weren’t spared. Radiation fared better. It gave that person a 6 in 10 chance of maintaining normal sexual activity. Brachytherapy, where the radiation seeds are implanted in the prostate, had the best prognosis, an 8 out of 10 chance of retaining some semblance of normalcy in sexual activity.

Of course, to achieve these outcomes, “this patient might require some assistance, most likely from a 5-phosphodiesterase inhibitor,” the editorial noted. Viagra and Cialis are drugs in this class.

Michael Barry of Massachusetts General Hospital, who serves on the board of the Foundation for Informed Medical Decision Making (FIMDM), concluded the editorial with a call for physicians to routinely sharing this information with patients so they can help decide which therapy to use.

A spinoff from work done at Dartmouth over the years on health care overutilization, FIMDM launched a for-profit arm called Health Dialog that works with insurance companies and health care delivery organizations to promote patients’ knowledge so they can participate in deciding their own medical fates. Can there be any doubt that if all prostate cancer patients became aware of the side effects of the various options for treating their disease, the number of patients who chose “watchful waiting” would rise exponentially?

Here’s what the Well Blog forgot to mention. According to the Prostate Cancer Intervention Versus Observation Trial (PIVOT), which followed men identified with localized prostate cancer from prostate-specific antigen (PSA) testing for 10 years, with half the group getting radical surgery and half following “watchful waiting,” there was no statistical difference in either all-cause or prostate cancer mortality among the two groups. Fewer than 10 percent of patients in either group died (a surprisingly low percentage given that the average age at the time of randomization was in the late 60s). And while there was a slight, non-significant 3% decrease of mortality in the surgery group, most of that was concentrated in those patients deemed at high risk based on analysis of their tumors and PSA scores.

What’s the moral of the story? When in doubt, don’t cut it out.