Fifteen-Year Outcome of Very Delayed Hormone Therapy (DHT) vs. Immediate Surgery

BY MARK SCHOLZ

In May 2011 the New England Journal of Medicine reported on 695 men from Sweden, Finland and Iceland, average age 65, who were randomly allocated to either immediate surgery or delayed hormone therapy (DHT) between 1989 and 1999.  The median PSA for the 695 men was 13. Eighty percent of the men had palpable disease on digital rectal exam. In the men treated with DHT, hormone therapy was initiated if and when bone metastasis occurred. Bone scans were performed every other year.

The following Table summarizes the findings of the study:

The results of this study are updated and republished every three years since it is the only randomized prospective trial that reports long-term survival figures for surgery. Surgeons commonly refer to the study to bolster their claim that surgery saves lives. However, the survival difference between the two groups is only 6%. In other words, by undergoing surgery, only one man benefits from delayed death from prostate cancer for every fifteen men who have unnecessary surgery.

The message from this study would seem to be that the survival advantage from surgery is real, just not very big. However, there are two problems with this conclusion. First, the way men in this study were treated would probably be considered malpractice by most doctors in the United States. Few doctors recommend forgoing therapy altogether in otherwise healthy men starting with a PSA of 13, as was the case in this study. And delaying hormone treatment until bone metastases occur is generally frowned upon as well.

This study documents a modest longevity advantage as a result of surgery in men with relatively advanced disease compared to men who undergo no treatment whatever. However, the longevity benefit will probably be much smaller or absent in men with earlier-stage disease who are watched closely and treated at the first sign of disease progression, the option commonly termed “active surveillance.”

One potential benefit of immediate surgery should be noted: The men treated with surgery had a 24% lower incidence of requiring hormone therapy down the line. This advantage should be factored into the quality-of-life decision-making process.