In the most recent of his regular video commentaries on the management of prostate cancer on the Medscape Oncology web site, Dr. Gerald Chodak discusses the recently published, final results of the PIVOT study, and argues that, “It is absolutely critical that we [i.e., the urology community and other physicians who treat prostate cancer] make sure that every man diagnosed with prostate cancer is aware of these results.”
The “New” Prostate Cancer InfoLink is in complete agreement with Dr. Chodak. Not only do physicians need to be advising their patients about the results of this trial. They also need to be doing so in a neutral and unbiased manner so as to help their patients make good decisions about how each individual patient wishes to be treated.
We now have data from the two largest trials completed to date (the PIVOT trial and the Scandinavian trial), both of which have clearly shown that, for men > 65 years of age with low- and very-low risk localized disease, there is no evidence of overall or prostate cancer-specific survival benefit from radical prostatectomy compared to observation.
We are quite sure that — despite these data — there will still be men with low-risk disease in this age group who are going to insist on surgery as a treatment for their prostate cancer. This is their right — but they now need to understand that there are no data to support such a decision in men > 65 years of age. In addition, those men who are already concerned about the benefits of surgery need to be able to hear that there are data from two good clinical trials that would support active surveillance or some other form of observation as opposed to surgery.
We do wish to emphasize, however, that there are also no data to suggest either of the following conclusions from the PIVOT study or the Scandinavian trial:
- Since surgery is no better than observation as a first-line treatment for low-risk, localized prostate cancer in men > 65 years of age, then no other form of treatment is effective either.
- Observation is a better management strategy than any form of treatment for low-risk, localized prostate cancer in men > 65 years of age.
What we actually now know is that we have no evidence that treatment is better or worse that observation for this category of men (a very high percentage of all those diagnosed each year with low-risk prostate cancer). Some may still prefer to “bite the bullet” and hope that treatment will still extend their personal life with limited side effects. Others are going to say, “Let’s simply avoid any risk for the side effects” and hope that not getting treated doesn’t lead to aggressive, metastatic disease. These are both valid, personal choices.
There is no “right” or “wrong” here in terms of the individual patient’s decision. “Right” and “wrong” are going to be confined to the will of the treating community to ensure that their patients receive a neutral explanation of the risks and benefits associated with the very available and very different approaches to patient care.