Information from www.cancer.org
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 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.
Men who are young and healthy are less likely to be offered active surveillance, out of concern that the cancer will become a problem over the next 20 or 30 years.
Not all experts agree how often testing should be done during active surveillance. There is also debate about when is the best time to start treatment if things change.
Watchful waiting (observation) is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and rely more on changes in a man’s symptoms to decide if treatment is needed.
Watchful waiting and active surveillance are reasonable options for some men with slow-growing cancers because it is not known whether treating the cancer with surgery or radiation will actually help them live longer. These treatments have definite risks and side effects that may outweigh the possible benefits for some men. Some men are not comfortable with this approach, and are willing to accept the possible side effects of active treatments to try to remove or destroy the cancer.
There have been a few large studies comparing watchful waiting (where men were treated only if they developed symptoms from their cancer) and surgery for early stage prostate cancer. In one study, where few of the patients had very early stage (T1) cancers, the men who had surgery lived longer. In another study, where about half of the men had very early stage cancers, there was no real survival advantage for treatment with surgery.
So far there have been no large studies comparing active surveillance to treatments such as surgery or radiation therapy. Some early studies of men who are good candidates for active surveillance have shown that only about a quarter of the men need to go on to treatment with radiation or surgery.
So why do 9 out of 10 men with prostate cancer in the U.S. end up being treated shortly after they’re diagnosed? It turns out that many prostate cancer patients have never heard of active surveillance or watchful waiting, and are never told that observation is an option they could consider for their cancer. In other cases, active surveillance is discussed as a potential management option but is presented in an unfavorable manner (i.e., “we can treat your cancer or we can just do nothing”).
Even in circumstances where active surveillance is discussed in a fair, objective manner, there are a number of other factors that may influence the likelihood of men choosing and sticking with this option. These include whether or not their physician supports their choice, the extent of support from family and friends, and the patients’ personal perceptions of and experience with cancer (whether they themselves have had other types of cancer in the past, or observed friends or family go through cancer treatment).
So if you or someone close to you has been diagnosed with prostate cancer — slow down! After getting past the shock, start asking some questions. Find out all that you can about the tumor, and determine whether the cancer fits into the low-risk category. Be sure to explore all treatment options, including active surveillance. In some cases of prostate cancer “no treatment” may turn out to be the best treatment.
Source: “To Treat or Not to Treat Prostate Cancer: That is the Question,” by Durado Brooks, MD, MPH. www.cancer.org
Photo credits: patrickheagney, monkeybusinessimages, bowdenimages/iStock
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:
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- 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 www.cancer.org.