Study: Not Treating Prostate Cancer Could Be Good Choice

By Sacha Pfeiffer
Aug 31, 2009, 5:12 PM
2 Comments

Advances in prostate cancer screening have helped save thousands of men’s lives. But early detection can lead to treatments that cause terrible side effects, even though the cancers were so small they posed no long-term health risks.

Now, new research out of Beth Israel Deaconess Medical Center in Boston shows that some men diagnosed with prostate cancer could be better off not getting treatment at all.

When scientists developed the prostate cancer test called PSA screening about 20 years ago, it began to find prostate cancers at much earlier stages. That meant men could start aggressive early treatment. But PSA screening has also been criticized for driving so much early detection that prostate cancer is now overdiagnosed.

“PSA screening is a double-edged sword,” said Martin Sanda, director of the Prostate Cancer Center at Beth Israel Deaconess, and an associate professor at Harvard Medical School.

Sanda said early detection has reduced prostate cancer deaths, but, he added, “the flip side is that in detecting these cancers so early, we recognize that they are not tumors that are apt to cause any harm in the near-term — or foreseeable future — for many men.”

Some men with prostate cancer can live their whole lives without any symptoms. But many men get treatment anyway as soon as they’re diagnosed. And those treatments — usually surgery or radiation — can cause sexual dysfunction and urinary and bowel problems that diminish their quality of life.

So Sanda and a group of other researchers at Brigham and Women’s Hospital, the Harvard School of Public Health, and the University of California at San Francisco, looked at more than 3,300 men diagnosed with prostate cancer between 1986 and 2007 and studied the outcomes of those who decided not to get treatment right away — or at all.

“About half of the patients who didn’t undergo treatment immediately, meaning in the first year when they were diagnosed, were still doing fine and had not undergone treatment 10 or 15 years later, which is quite a lot of patients,” Sanda said.

The study also shows that the difference in death rates between men who had and hadn’t sought treatment was statistically insignificant. Sanda cautioned that the men who didn’t seek treatment had been diagnosed with small, low-risk tumors. So the no-treatment option isn’t right for everyone, he said.

But Sanda said that what he calls “watchful waiting” is one of the options that men with low-risk prostate tumors should consider.

“Throwing yet another option in the mix in many ways doesn’t make the decision easier for patients or their doctors,” he said. “But it’s a very important option to put on the table: Is this man’s cancer one that needs to be treated right away, or is it one that can be monitored?”

The idea that a cancer wouldn’t immediately be treated can require a major change of thinking.

“When I was in medical school, I was told that if it’s a tumor, when in doubt, cut it out,” said Jonathan W. Simons, president and chief executive officer of the Prostate Cancer Foundation in Santa Monica, Calif. “This study shows that if it’s a very low-grade, low-stage, low-risk tumor, patients should understand they may not need surgery immediately, or radiation.”

Simons also said the new study suggests PSA screening has a potentially new role: to help patients determine what kind of prostate cancer they have — low-risk or high-risk — and plan their treatment regimens accordingly.

But he noted the decision not to treat prostate cancer immediately requires a different kind of commitment.

“In making the decision that you may not need surgery, you have to make the decision that you need to be much more carefully monitored the rest of your life,” he said.

And for many men diagnosed with prostate cancer, that lifelong vigilance could be worth the trade-off.

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http://www.menletter.org Tim Baehr

Useful story, but some information was left out. PSA screening is only a first step (along with the rectal exam) in diagnosis. Unless the initial number is very high, men should insist on retesting after six months to see if the PSA is increasing and/or the lump or hard area on the prostate has grown. A rapid increase in PSA can indicate a more aggressive form of the disease. They should also insist on a test dividing PSA into bound PSA and unbound PSA. A high ratio of bound PSA often indicates PSA that is bound to a tumor. Ultrasound, biopsy, and MRI are not that horribly invasive, but they can give the location of the tumor and the severity (or grade) of the cancerous area. All of these, plus a man’s age and general health, can go into making an informed decision about whether, and how, to treat. Even with a definitive diagnosis, there is no one-size-fits-all way to proceed.

Seventeen percent of men will be diagnosed with prostate cancer at some time in their lives. The rate is closer to 35 percent for men with a close relative who has had the cancer. If you had a car with either of those rates of problems, would you just drive it and hope for the best?

Death from prostate cancer that has spread (to the spine, for instance) can be prolonged and exceedingly painful, not to mention expensive. Not testing, or testing and then adopting “watchful waiting” based on one elevated PSA, is like playing Russian Roulette with one or two bullets in the gun. PSA screening alone may not save lives; PSA testing and appropriate followup certainly saved mine and those of many other men.
http://www.bidmc.org/prostate Martin Sanda

The first paragraph of Tim Baehr’s comments is right on target: prostate cancer care needs to be individualized. However, Tim is mistaken in his assumption that watchful waiting is based on a single PSA and biopsy result and is therefore ‘Russian Roulette’ – this term reflects the “old school” of watchful waiting, where cancers were essentially ignored (no really even watched) after diagnosis – that, however, is NOT what is done when watchful waiting is used nowadays. There are 2 key points in this regard: First, watchful waiting has evolved into what is now called “active surveillance” because it now involves REPEATED PSA testing, re-biopsy, and imaging. Second, the intent of contemporary “active surveillance” is to TREAT AND CURE prostate cnacer, but to limit such treatment to only those cancers that have the biological capability to grow and/or spread – this would include most cancers with Gleason score 7 or highger, but only one-half of Gleaon score 6 cancers. Through this approach, about half of the men with low risk cancers who start out “waiting” do eventually wind up going on to curative therapy, whereas the other half remain free of treatment or cancer progression. My recommendation to any man diagnosed with prostate cancer: get a second opinion before deciding what to do, and bring a spouse or friend or family member with you to at least one of the consultations, as there is alot of information to sort out to make the best decision, which may differ from one patient to the next. Be wary of “cookbook” recommendations or generalizaitons such as deciding on treatment based simply on age or any other single factor. Finally, seek multidisciplinary clinic evaluations, that is one setting where individual doctor’s biases can be kept in check.