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Previous Volume 360:e4 January 15, 2009 Number 3

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In early December, we presented the case of a 63-year-old man with a rising prostate-specific antigen (PSA) level in Clinical Decisions,¹ an interactive feature designed to assess how readers would manage a clinical problem for which there may be more than one appropriate treatment. The patient had no symptoms and was physically and sexually active. Biopsy of the prostate revealed adenocarcinoma with a Gleason score of 6 in 2 of 12 biopsy cores.

Among the 3720 votes cast, 29% were for expectant management, 33% for radiotherapy, and 39% for radical prostatectomy. The votes that could be attributed to a continent or region came from North and Central America (a total of 2046), Europe (759), South America (465), Asia and Russia (266), Australia and Oceania (97), and Africa (42). Most voters were physicians, but some were students or patients who had received treatment for prostate cancer (Figure 1). In addition to the votes, we received 218 comments, of which 195 are posted at NEJM.org.

View larger version (36K): [in this window] [in a new window]   Figure 1. Percentage of Participants Choosing Each Treatment Option for the Management of Prostate Cancer. The total number of participants who voted and the percentage who chose each option are shown for each continent or region. An interactive graphic that includes the total number of votes and percentages according to country is available at NEJM.org

 
The almost even distribution of votes among the three options is somewhat surprising. This result most likely reflects the lack of a large, rigorous, decisive head-to-head clinical trial in which radiotherapy is compared with radical prostatectomy. Many voters who favored expectant management actually wanted to wait several months to determine whether the PSA continued to rise and to observe the rate of rise. Many stressed the strict discipline that would be required by the patient and his physician for active surveillance to be successful. A recurrent theme in the comments from voters for expectant management, expressed by one such voter, was, "It seems to me very reasonable and without a major risk for the patient to conserve his sexual and urinary quality of life during the next years." Also noted repeatedly were the psychosocial consequences of the alternative choices.

Readers who voted in favor of radiotherapy and commented on their vote were inclined to emphasize that the risks of incontinence and impotence were lower after brachytherapy (the placement of radioactive seeds) than after radical prostatectomy. One commenter summed up the problem this way: "There are no randomized controlled trials regarding prostatectomy or radiation modalities but all studies and guidelines support surgery, external-beam radiation or brachytherapy as similar treatment options. My personal bias is about permanent brachytherapy."

Comments in favor of prostatectomy stressed the long life expectancy of the patient, his lack of coexisting conditions, and the relatively small size of his prostate. Many commenters emphasized the importance of the surgeon's level of experience in performing a nerve-sparing prostatectomy, and several noted that they found it impossible to check on the record of an individual urologic surgeon. One comment — "This man is relatively young. So don't mess around with it — get it out!" — summarizes the feeling of many who voted in favor of surgery.

The even distribution of opinions we received from over 2600 physicians about the management of prostate cancer is a compelling argument in favor of a definitive clinical trial to settle the issue of radiotherapy versus surgery. Most voters for expectant management were actually voting for a delay before invasive treatment, not for years of such management. Ultimately, most voters in favor of expectant management would have to choose a treatment.

References

1. Schröder FH, Roach M III, Scardino P. Clinical decisions: management of prostate cancer. N Engl J Med 2008;359:2605-2609. [Free Full Text]

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