One of the thorniest dilemmas posed by prostate cancer is whether, and when, to give radiation therapy – with its potential bad side effects – to men after surgery to remove the prostate gland. Now, three new randomised clinical trials and a statistical “meta-analysis” of their results conclude that routinely giving post-surgical radiation does not improve outcomes after five years, compared with giving radiation only if the PSA (prostate specific antigen) blood test signals a cancer recurrence. The papers were published last month in The Lancet and The Lancet Oncology . “All the surgeons have always struggled with this,” said Alexander Kutikov, a urological oncologist at the Fox Chase Cancer Centre in the US city of Philadelphia, in the state of Pennsylvania. “You don’t want to overtreat, but you don’t want to lose the window of opportunity. These trials really crystallise that you can hold off on radiation. It has changed my practice.” That change has benefited not only Kutikov’s post-surgical patients, but also men like James Boughter, 56, a Philadelphia-based machinist who had surgery six years ago. ‘If you are shy, you will suffer’: men and prostate cancer “We were keeping an eye on [the PSA] every six months,” said Boughter, whose PSA became detectable – barely – about a year ago, but has been stable at that low level. Based on the latest research, Kutikov assured Boughter that he could hold off on radiation, and hopefully forgo it altogether. “If I had to do radiation, I would definitely do it if it’s going to take care of the cancer. But I’d rather not,” Boughter said, because of the risks of urinary or other problems. The studies could spare many men from overtreatment, said Claire Vale, a researcher at University College London who led the meta-analysis. “Guidelines and policy regarding the standard of care for prostate cancer should be updated based on the findings.” Prostate cancer diagnosis and treatment is fraught with risk-benefit trade-offs, starting with PSA testing to screen for the disease. Current guidelines say doctors should not do routine screening without first discussing concerns that it leads to finding and treating tiny cancers that would never have become a threat if left alone. When early-stage cancer is found, the gold-standard treatment – especially in younger men – is surgical removal of the walnut-sized prostate gland. But studies suggest that up to 40 per cent of men – Boughter among them – may be at high risk of recurrence despite surgery. That could be because the cancer was aggressive, or some malignant cells escaped during surgery, or the cancer had spread to tissue near the prostate. The idea [of post-surgical radiation therapy] was always that you were missing an opportunity [for a cure]. These studies tell me we can hold off Alexander Kutikov, urological oncologist, Fox Chase Cancer Centre Seven previous randomised trials have tried, and failed, to definitively answer which men, if any, benefit from post-surgical radiation rather than waiting until the PSA rises. Some of the studies didn’t monitor the PSA level, or didn’t give radiation until the cancer was advanced, or both, so the results were hard to interpret. The new studies also have some possible limitations, according to authors of an accompanying commentary. For example, one trial enrolled men who would not normally receive post-surgical radiation because of their favourable risk profile. The three trials also varied in their use of drugs that block the hormones that fuel prostate cancer. “Nonetheless, the … studies represent an important step forward and support” adding radiation only if the cancer comes back, wrote Derya Tilki of the University Hospital Hamburg-Eppendorf in Germany, and Anthony D’Amico of the Dana-Farber Cancer Institute in Boston, in the US state of Massachusetts. Does diet affect prostate cancer and when should men get tested? The meta-analysis, which included 2,153 patients followed for an average of five years, found that 88 per cent of men who held off on radiation did not have a relapse, compared with 85 per cent who had radiation soon after surgery. Among those who held off, 67 per cent still didn’t need radiation up to eight years later. Urinary incontinence was worse at one year for men with post-surgical radiation: 6 per cent of them had difficulty urinating because of damage to the urethra, compared to 4 per cent of men who postponed radiation. “The idea was always that you were missing an opportunity” for a cure, Kutikov said. “These studies tell me we can hold off, even in those men” at higher risk of recurrence.