Prostate Cancer: To Treat or Not to Treat?
Clark Howard was in Shanghai on a business trip in 2009 when his wife called him, tearful and anguished. A biopsy showed that Howard, then 53, had prostate cancer. When he returned home to Atlanta, his doctor recommended either surgery to remove his prostate gland or radiation therapy, the standard response to such a diagnosis at the time. But while in Shanghai, Howard had read a series of medical journal articles about prostate cancer. The articles suggested that for some prostate cancer patients in Europe, no treatment worked out fine.
"You could have a cancer that was OK to monitor, rather than jump all over it right away," he says. To the dismay of his prospective surgeon, Howard opted for that approach, which is known as "active surveillance." It's an option that has become widely accepted and adopted in the medical community during the last 10 years as a way of reducing unnecessary treatment of prostate cancer, says Dr. Ballentine Carter, an oncologist at Johns Hopkins Hospital in Baltimore.
Active surveillance is working for Howard: Ten years after being diagnosed, his prostate cancer hasn't spread, and his doctor says he's in good health. Howard isn't an outlier. In 2016, the New England Journal of Medicine published a 10-year study of more than 1,643 men between ages 50 and 69 who were diagnosed with localized prostate cancer. Researchers found no significant difference in the mortality rate between men who were under active surveillance and those who had prostate surgery or radiation treatment. "Based on this data, the use of active surveillance is now the commonest way to manage men with newly diagnosed low-grade cancers in the U.S.," says Dr. Eric A. Klein, chairman of the Glickman Urological and Kidney Institute at the Cleveland Clinic.
[See: Questions to Ask Your Doctor About Prostate Cancer.]
Here are the potential side effects facing men who undergo the typical treatment options for prostate cancer:
Side Effects of Prostate Surgery:
-- Urinary problems like incontinence.
-- A poor reaction to anesthesia.
-- Blood clots
-- Infections.
Side Effects From Radiation for Prostate Cancer:
-- Erectile dysfunction.
-- Irritation of the bladder and urinary tract.
-- Bowel symptoms.
Inactive Prostate Cancer
In the U.S., there are nearly 175,000 new cases of prostate cancer annually, according to the American Cancer Society. About 60% are diagnosed in men ages 65 or older, and the occurrence of prostate cancer in men younger than 40 is rare. Prostate cancer is the second-leading cause of cancer death among men in the U.S., trailing only lung cancer. About 1 in 9 men will be diagnosed with prostate cancer in his lifetime. Overall, more than 30% of men who are diagnosed with prostate cancer will have a type that is "indolent," says Dr. Jonathan W. Simons, an oncologist who is president and chief executive officer of the Prostate Cancer Foundation. That means the cancer is basically lacking the ability to metastasize and become life-threatening, he says. Consequently, the typical treatments for prostate cancer -- radiation or surgery to remove the prostate gland -- aren't necessary, Simons says.
[See: What's the Best Diet for Prostate Cancer?]
Which Patients Are Good Candidates for Active Surveillance?
Doctors use a scoring system to determine which prostate cancer patients are at low risk of having their cancer spread and who therefore should opt for active surveillance. Typically, a urologist does a biopsy to remove small samples of tissue in different areas of the prostate gland, then a pathologist assigns a grade if cancer is present, Carter says. The grade is a way of determining the aggressiveness of the cancer on a scale known as the Gleason score. Gleason scores range from 6 to 10, with higher numbers indicating more aggressive cancer. "A Gleason score of 7 to 10 indicates a more aggressive cancer that is at higher risk of spreading than a Gleason 6 score," Simons says. "Patients should talk to their doctor about shared decision-making based on their biopsy results and other clinical factors, like your family history of cancer." Patients with a Gleason score of 6 or less should talk to their doctors about whether active surveillance is a viable option for them.
Active surveillance doesn't mean doing nothing, Simons says. The approach typically means the patient needs to see his urologist once or twice a year for a PSA blood test (which screens for a prostate-specific antigen in the blood) and a digital rectal exam, according to the Prostate Cancer Foundation. A biopsy of the prostate should be conducted every one to five years, according to the foundation. "Active surveillance means you can't miss your appointment," Simons says. For patients on active surveillance, the concern isn't that their prostate cancer will become more aggressive, he says. Rather, someone with low-level prostate cancer is at risk of having another, more aggressive form of prostate cancer develop. "We don't want to over-treat, and we don't want to miss a second, more aggressive cancer," he says. Men who are at higher risk of prostate cancer -- such as African-Americans or patients who have a family history of cancer -- should talk to their doctors about any additional monitoring they should undergo, says Janet Farrar Worthington, who's co-written several books on prostate cancer.
MRIs Help Monitor Prostate Cancer
Some physicians use MRIs as part of active surveillance. For example, doctors at Johns Hopkins Hospital typically have a prostate cancer patient who's on active surveillance undergo an MRI every two to four years, Carter says. Using the patient's data -- PSA and biopsy results -- doctors have created an algorithm to predict the trajectory of a patient's cancer, he says. The approach is comparable to how meteorologists use data and algorithms to predict hurricanes. Many cancer centers also use blood and urine tests and examinations of tumor genes to assess cancer, Carter says.
A diagnosis of prostate cancer can be understandably scary, but it's not a reason to panic, Carter says. It's crucial for men who are diagnosed with the disease to undergo the necessary tests to determine its aggressiveness, and to talk to their doctor to decide whether they need prostate cancer treatment. "The first step is to determine whether treatment is necessary, and if so, which approach is best for that individual," he says. "There is a very large proportion of individuals who get diagnosed today who can forgo treatment safely."
Dr. Edward M. Schaeffer, chair of the department of urology at the Northwestern University Feinberg School of Medicine, agrees. "Active surveillance has proven to be a safe and effective way to manage men with small amounts of minimally aggressive prostate cancer," he says. "While under careful surveillance, the risk of developing advanced cancer is less than 0.5% over 10 years and the risk of death is effectively zero."
[See: 10 Innovations in Cancer Therapy. ]
Here are three facts to keep in mind about active surveillance:
-- More than one-third of men diagnosed with prostate cancer can manage it with active surveillance.
-- Active surveillance is a continuous process that involves monitoring of the patient with various tests.
-- When done carefully, active surveillance is safe and progression to a widespread cancer is very rare.
