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How Delaying Prostate Cancer Treatment Could Improve Survival

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Prostate cancer is one of the most common types of cancer that men can develop. Early detection is crucial to ensure the best possible outcomes, but it is important to know that not all cases of prostate cancer require immediate treatment. For many men, active surveillance is a viable option that allows them to delay aggressive treatment and avoid the challenging side effects associated with it. The ProtecT clinical trial has shown that delaying prostate cancer treatment can be a safe alternative for many patients.

The ProtecT Clinical Trial

The ProtecT trial was launched in 1999 by British researchers to compare outcomes among men who were either treated immediately for their cancer or followed on active surveillance (then called active monitoring). The men's average age at enrollment was 62, and they all had low- to intermediate-risk tumors with prostate-specific antigen (PSA) levels ranging from 3.0 to 18.9 nanograms per milliliter.

During the study, researchers randomized 545 men to active monitoring, 533 men to surgical removal of the prostate, and 545 men to radiation. After 15 years, 356 men had died from any cause, including 45 men who died from prostate cancer specifically: 17 from the active monitoring group, 12 from the surgery group, and 16 from the radiation group.

It is worth noting that men in the active surveillance group did have higher rates of cancer progression than the treated men did. More of them were eventually treated with drugs that suppress testosterone, a hormone that fuels prostate cancer growth. In all, 51 men from the active surveillance group developed metastatic prostate cancer, which is roughly twice the number of those treated with surgery or radiation. However, 133 men in the active surveillance group also avoided any treatment and were still alive when the follow-up concluded.

The Findings of the Study

The study's long-term results, published in March, revealed that prostate cancer death rates were low regardless of the therapeutic strategy. "This hugely important study shows quite clearly that there is no urgency to treat men with low- and even favorable intermediate-risk prostate cancer," says Dr. Anthony Zietman, a professor of radiation oncology who was involved in the research and is a member of the Harvard Medical School Annual Report on Prostate Diseases editorial board. "They give up nothing in terms of 15-year survival."

The findings suggest that for some men, aggressive therapy "results in more harm than good," says Dr. Freddie Hamdy of the University of Oxford, the study's lead author. While cancer progression and the need for hormonal therapy were more limited in the treatment groups, "those reductions did not translate into differences in mortality."

Dr. Zietman agrees, adding that active surveillance protocols today are even safer than those used when ProtecT was initiated. Unlike in the past, active surveillance protocols now make more use of magnetic resonance imaging (MRI) scans that detect cancer progression in the prostate with high resolution.

The Benefits and Risks of Active Surveillance

Active surveillance is a strategy used by doctors to monitor patients with low-risk prostate cancer without administering aggressive treatment. This approach involves regular testing and check-ups, including PSA tests and biopsies, to determine if the cancer is progressing.

Active surveillance is a viable option for men with low-risk prostate cancer, but it does come with some risks. Patients who choose this option run the risk of delaying treatment and allowing the cancer to progress. They also face the potential psychological stress and anxiety of living with a cancer diagnosis.

Who Can Benefit from Active Surveillance?

Active surveillance is most commonly recommended for men with low-risk prostate cancer. This includes men with a PSA level of less than 10 ng/mL, a Gleason score of 6 or less, and a cancer stage that is localized to the prostate gland.

Men with intermediate-risk prostate cancer may also be eligible for active surveillance if their cancer has a low volume, and they have a PSA level of less than 15 ng/mL and a Gleason score of 7.

However, men with high-risk prostate cancer typically require immediate treatment, as the cancer is more aggressive and more likely to spread beyond the prostate gland.

The Importance of Regular Check-Ups

Regardless of the treatment approach chosen, it is crucial for men with prostate cancer to receive regular check-ups and follow-up care to ensure the cancer is not progressing.

Routine check-ups typically involve PSA tests and digital rectal exams to monitor for changes in the prostate gland. Imaging tests like MRI or CT scans may also be used to detect cancer progression or spread.

It is essential for men with prostate cancer to work closely with their doctors and follow their recommended treatment plan. Delaying treatment without proper monitoring can lead to cancer progression and a higher risk of complications.


Prostate cancer is a common and potentially life-threatening condition that requires careful monitoring and treatment. The ProtecT clinical trial has shown that delaying treatment through active surveillance can be a safe alternative for many patients with low-risk or favorable intermediate-risk prostate cancer.

However, active surveillance is not suitable for all men with prostate cancer, and it is essential for patients to work closely with their doctors to determine the best treatment approach for their individual needs.

Regular check-ups and monitoring are crucial to ensure the cancer is not progressing, regardless of the treatment approach chosen. By working closely with their healthcare providers, men with prostate cancer can increase their chances of a successful outcome and improved survival.

Howard E. Stanton, MD

Howard Stanton, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston.

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