Poll results: Trial needed to compare prostatectomy, radiotherapy

Results of an interactive feature on the web site of the New England Journal of Medicine suggest a need for a large, rigorous, decisive head-to-head clinical trial comparing radiotherapy and surgery for the treatment of prostate cancer.

Robert S. Schwartz, MD, professor of medicine at Tufts School of Medicine, Boston, and a deputy editor of the New England Journal of Medicine, presented the case of a 63-year-old man with a rising PSA. The patient had no symptoms and was physically and sexually active. Biopsy of the prostate revealed adenocarcinoma with a Gleason score of 6 in two of 12 biopsy cores.

A web-based poll, designed to assess how readers would manage a clinical problem for which there may be more than one appropriate prostate cancer treatment, accompanied the case. Among the 3,720 votes cast by readers, 29% were for expectant management, 33% for radiotherapy, and 39% for radical prostatectomy. Most voters were physicians, but some were students or patients who had received treatment for prostate cancer.The almost even distribution of votes among the three options is somewhat surprising, Dr. Schwartz said (N Engl J Med 2009; 360:e4). Many voters who favored expectant management wanted to wait several months to determine whether the PSA continued to rise and to observe the rate of rise. Readers who favored radiotherapy were inclined to emphasize that the risks of incontinence and impotence were lower after brachytherapy than after radical prostatectomy.

Comments in favor of prostatectomy cited the long life expectancy of the patient, his lack of concomitant conditions, and the relatively small gland size, as well as the surgeon’s experience in performing a nerve-sparing prostatectomy, albeit several respondents said it was it impossible to check on the record of individual urologic surgeons.

“The even distribution of opinions from more than 2,600 physician respondents 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,” Dr. Schwartz wrote.