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Is NOT Treating Prostate Cancer a Possibility?

  August 07, 2015

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Imagine being told by your doctor, “You have cancer.” Then imagine that their next words are “... but we probably don’t need to do anything about it.” Many people would immediately start looking for another doctor. But hold on just a moment.

Not treating cancer?
To most individuals, the idea of having cancer and choosing not to treat it smacks of fatalism, or just giving up. In order to understand why this is not the case, it is important to appreciate that all prostate cancers are not created equal.

There are many prostate cancers that can be singled out as likely to be slow growing and posing a low risk to the affected man. These can be identified by:
  • PSA level (prostate specific antigen): A protein made by the prostate gland and measured in the blood)
  • Gleason score: A numerical representation of how a man’s tumor looks under the microscope
  • Other factors: Size of the tumor, how much of the prostate gland is invaded by cancer, etc.
The vast majority of men with these low-risk tumors will end up dying of something other than prostate cancer, and few of these men would ever experience any harm from their cancer if it went untreated (or if it was never found in the first place).

It’s estimated that as many as half of the prostate cancers diagnosed each year in the U.S. fit into this low-risk category. However, to most people the term “low-risk cancer” sounds like an oxymoron. This quandary prompted some experts  to question whether this type of tumor should even be called “cancer,” or if the scientific community should come up with a new, less frightening term to describe these slow growing prostate lesions.

For most men who are told that they have prostate cancer, the first question is, “How soon can we get rid of it?” In the U.S., 90 percent of these men move very rapidly to what is viewed as definitive therapy, usually prostatectomy (surgical removal of the prostate gland), or killing the cancer cells with radiation treatment. These treatments come with the risk of side effects and complications: most commonly, damage to bladder or bowel function, and sexual difficulties. A recent report from the U.S. Preventive Services Task Force estimates that one or more of these complications occur in up to 30 of every 100 men treated for prostate cancer; the same report indicates that 1 of every 200 men who undergo surgical removal of their prostate die within 30 days of their surgery. These numbers point to why it’s so important to explore alternative approaches to managing this disease.

Expectant Management, Watchful Waiting, and Active Surveillance 
Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) might never need treatment for their prostate cancer. Instead, their doctors may recommend approaches known as expectant management, watchful waiting, observation, or active surveillance.

Some doctors use these terms to mean the same thing. For other doctors, the terms “active surveillance” and “watchful waiting” mean something slightly different. Not all doctors agree with these definitions or use them exactly this way. In fact, some doctors prefer to no longer use the term watchful waiting. They feel it implies that nothing is being done, when in fact a man is still being closely monitored. No matter which term your doctor uses, it’s very important to understand exactly what he or she means when they refer to it.

Active Surveillance 
Active surveillance is often used to mean monitoring the cancer closely with prostate-specific antigen (PSA) blood tests, digital rectal exams (DREs), and ultrasounds at regular intervals to see if the cancer is growing. Transrectal ultrasound-guided prostate biopsies may be done every year as well to see if the cancer is becoming more aggressive. If there were a change in your test results, your doctor would then talk to you about treatment options.

On biopsies, an increase in the Gleason score or extent of tumor (based on the number of biopsy samples containing tumor) are both signals to start treatment (usually surgery or radiation therapy).

In active surveillance, only men whose cancer is growing (and therefore have a more serious form of cancer) are treated. This allows men with less serious cancer avoid the side effects of a treatment that might not have helped them live longer. A possible downside of this approach is that it might give the cancer a chance to grow and spread. This might limit your treatment options, and could possibly affect the chances of curing the cancer.

What should you ask your doctor about prostate cancer?

It’s important for you to have honest, open discussions with your cancer care team. They want to answer all of your questions, no matter how minor you might think they are. For instance, consider asking these questions:
  • What are the chances that the cancer has spread beyond my prostate? If so, is it still curable?
  • What further tests (if any) do you recommend, and why?
  • Are there other types of doctors I should talk to before deciding on treatment?
  • What is the clinical stage and Gleason score (grade) of my cancer? What do those mean to me? Does this make me a low-risk, intermediate-risk or high-risk patient?
  • What is my expected survival rate based on clinical stage, grade, and various treatment options?
  • Do you recommend a radical prostatectomy or radiation? Why or why not?
  • Should I consider laparoscopic or robot-assisted prostatectomy?
  • What types of radiation therapy might work best for me?
  • What other treatment(s) might be right for me? Why?
  • What risks or side effects should I expect from my treatment options?
  • What are the chances that I will have problems with incontinence or impotence?
  • What are the chances that I will have other urinary or rectal problems?
  • How quickly do I need to decide on treatment?
  • What should I do to be ready for treatment?
  • How long will treatment last? What will it be like? Where will it be done?
  • How would treatment affect my daily activities?
  • What are the chances my cancer will come back with the treatment plans we have discussed? What would be our next step if this happened?
  • What type of follow-up will I need after treatment?
  • Where can I find more information and support?
Keep in mind that doctors aren’t the only ones who can give you information. Other health care professionals, such as nurses and social workers, may have the answers to some of your questions. You can find out more about speaking with your health care team in the document “Talking With Your Doctor”  on Back to Top

August 07, 2015

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