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Watchful waiting works best for some prostate cancers

Because some prostate cancers grow so slowly that they never produce symptoms, one option is a concept known as watchful waiting, or active surveillance. It's been in the news a lot lately as some experts have questioned whether men are getting unneeded treatments. Here are answers to questions you may have about it:

What is watchful waiting?

Also known as active surveillance, it means that when cancer is diagnosed, the patient and doctor decide not to use traditional treatments (surgery, radiation or seed implants). Instead, the cancer is monitored using PSA tests and biopsies to see if the cancer is growing aggressively. If so, the patient can choose to start treatment.

Why bother getting screened if you're not going to do anything about a diagnosis?

Active surveillance is not the same as doing nothing. In fact, it takes a patient and doctor who are willing to work very closely as a team to monitor the cancer and make decisions based on what the tests reveal.

Who might be a candidate for active surveillance?

A patient with a tumor that is small, and appears not to be aggressive. The guidelines are: fewer than three positive cancer biopsy cores of less than 3 mm total length, and with cancer involvement of less than 50 percent in any core. I also advocate taking more than the standard 12 cores, preferably 20 or more, often called "saturation" biopsies. The PSA has to be less than 10 and the Gleason Score less than 7.

What are the risks of active surveillance?

The screening methods aren't infallible. The risk is failing to detect aggressive disease types that spread during the monitoring period, missing the window of curability. There have been studies looking at samples from men considered eligible for watchful waiting, but who decided to have surgery anyway. They found that 3 to 4 percent of patients actually had a more dangerous tumor than preoperative testing indicated. So misclassification is the major concern.

What does this all mean for men with high risk of developing prostate cancer because of family history or race?

High risk patients — which includes African-Americans — may not be candidates, because they are more likely to have a cancer type that tends to grow more aggressively.

Why would anyone with a cancer diagnosis not want to get their tumor removed?

Some studies have found that if a patient is carefully followed, progression won't occur past the point where treatment can be used. So the patient avoids the pain and expense of needless treatment and related complications.

How do men cope emotionally with having untreated cancer?

Not everyone can develop the mindset you need to live with cancer. One-third of men in some studies eventually chose treatment because of anxiety about this approach.

But men who are older, or who have other significant medical problems, might choose active surveillance, deciding that something other than prostate cancer is likely to end their lives.

What are some other issues to consider?

When prostate cancer is found early, you can take your time in determining the treatment that's right for you. Seek second and third opinions, and do your research. No one is harmed in their curability over 18 months, if they fit the strict criteria and are followed properly by an experienced urologist. This requires a PSA every three to six months and a biopsy at least yearly or sooner if the PSA is rising quickly. This approach gives the man the opportunity to watch his cancer, and possibly avoid aggressive treatment.

Sounds like you're taking your chances either way.

I would call it an educated bet. Scientists are working on gene tests to determine which cancers are slow growing or aggressive, and that will help decision making. But for now, there is no simple answer.

Dr. Sharkey is a prostate cancer educational consultant in Palm Harbor and was in full-time urological practice for 40 years. Contact him at (727) 786-4531 or at urologyhealth@yahoo.com.

screening and treatment

For a full discussion of screening and treatment, please see Dr. Jerrold Sharkey's earlier Personal Best columns online at tampabay.com/health.

Watchful waiting works best for some prostate cancers 03/26/10 [Last modified: Thursday, March 25, 2010 11:47pm]
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