Prostate Cancer: To Treat or Not to Treat?

Many of the 240,000 American men diagnosed with prostate cancer every year receive their scary-sounding diagnosis along with a proclamation from their doctor that it may not need to be treated immediately -- or perhaps ever. The practice, called active surveillance, has become more popular over the past decade as studies suggest that prostate cancers caught in the earliest stages -- usually through a prostate-specific antigen or PSA screening blood test -- often don't grow quickly enough to spread and become life threatening.

For example, a 2012 landmark clinical trial published in the New England Journal of Medicine found that 731 men diagnosed with low-risk prostate cancer who were given the option of immediate surgery or observation had about the same risk of dying from prostate cancer, or any cause, over a 12-year period regardless of whether they had immediate treatment or opted for watchful waiting. The risk of dying from prostate cancer during the study was small for both groups -- less than 10 percent.

"There are certain criteria and factors we take into consideration before recommending active surveillance to our patients," says Ballentine Carter, an oncologist and director of adult urology at Johns Hopkins Hospital in Baltimore. These include tumor size, aggressiveness of the cancer cells, PSA level and amount of cancer found on the biopsy.

Age may also be a factor. Doctors are more likely to recommend immediate treatment for younger patients diagnosed with early-stage disease who are in good health and expected to live for another 20 or 30 years -- possibly long enough for the prostate cancer to turn deadly.

"Since the disease has such a long natural history, a man who is 65 or over with less aggressive cancer, in my opinion, shouldn't be asking what kind of treatment to get but whether he needs any treatment at all," Carter says.

Men in their 50s, however, may also be good candidates for active surveillance as cancer centers have become more comfortable with the practice of monitoring men for years or even decades.

How much monitoring patients get when they opt for active surveillance depends on the oncologist and institution providing treatment, Carter says. Men typically get rectal exams and PSA screening twice a year and regular biopsies of their prostate gland about every two years.

Determining which patients have low-risk prostate cancer that can be safely watched also depends on the medical provider, as well as a patient's own preference. A needle biopsy -- in which a urologist removes small samples of tissue in 12 areas throughout the prostate gland -- will determine the severity of the cancer, known as a Gleason score, in each of the 12 samples.

The scoring system assigns a number from 2 to 10 to describe how abnormal cells look under the microscope. A score of 2 to 4 means the cells look similar to normal cells and have little likelihood of spreading rapidly. A score of 8 to 10 means the cancer is aggressive and likely to spread, while a score of 5 to 7 indicates intermediate risk.

"The guidelines at most cancer centers recommend that, at a minimum, men should be strongly considered to be good candidates for active surveillance if they have a Gleason score of 6 or below in two or fewer of the biopsy samples," says Philip Kantoff, director of the Lank Center for Genitourinary Oncology at Dana-Farber Cancer Institute in Boston.

Others with a Gleason score of 7 or with cancer cells in three or four tissue samples may also choose monitoring after a careful discussion with their doctor about the risks and benefits of forgoing treatment. "Those cancers are more likely to progress and require treatment, but the majority of these patients do well even if they choose initial monitoring," Kantoff says.

A strong argument in favor of delaying treatment for early-stage prostate cancer: side effects associated with the surgery or radiation treatments. These most commonly include damage to the bladder or bowel resulting in urinary or fecal incontinence and sexual difficulties, such as impotence. About 30 out of every 100 men treated for prostate cancer experience one or more of these side effects, according to a recent report from the U.S. Preventive Services Task Force. The report also found that 1 in every 200 men who undergoes surgical removal of the prostate dies within a month of surgery.

If you have prostate cancer and you're uncertain about whether to have immediate treatment or active surveillance, you might gain additional insight from newer tests some cancer centers are offering, designed to help clarify a patient's prognosis. One is an imaging test called multiparametric magnetic resonance imaging, which combines several kinds of MRI imaging techniques to determine the extent of cancerous tissue in the prostate gland by evaluating certain chemical levels, blood flow to tissues and cell density.

"There is growing evidence that multiparametric MRI is a more sensitive method for detecting aggressive, high-grade cancer," Carter says, "but hospitals need good technicians to process the images and read them properly." Most smaller community hospitals don't have the requisite imaging expertise at this point.

Johns Hopkins Hospital and a few other cancer centers also do a blood test to check for tumor suppressor genes, since the absence of these genes has been associated with a higher risk of death from prostate cancer -- and could help make the case for immediate treatment. On the flip side, Carter says, "having these genes can reassure patients with early-stage cancer that we think their tumors can be managed safely with surveillance."

At Dana-Farber, Kantoff says both of these tests are still considered experimental and performed only in a research setting.

Kantoff's bottom-line advice for any man diagnosed with prostate cancer? "Don't freak out, and don't feel like you have to be immediately treated," he says. "Get opinions from at least two or three doctors. It's a complex decision."