Watching The Results On Watchful Waiting For Prostate Cancer

I have seen many changes in medicine during my 35 year career but nothing has changed more dramatically than the diagnosis and treatment of prostate cancer. When I was a medical student in 1968, the treatment was primarily removing a man’s testicles or castration. This drastic treatment removed the source of testosterone, which was the “fuel” to cause prostate cancer to grow. Then came surgery and radiation therapy followed by chemotherapy and now high energy focused ultrasound or HIFU. But many of these treatments have significant side effects like impotence and urinary incontinence which significantly impact a man’s quality of life. As a result conservative forms of treatment have been sought after that doen’t have the side effects and yet prolongs a man’s life. One of those options is watchful waiting or active surveillance where the diagnosis is made and no treatment is used and the man returns regularly for a physical examination which incldues a digital rectal exam, a PSA test and perhaps a repeat prostate ultrasound examination.

Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) may never need treatment for their prostate cancer. Instead, your doctor may recommend approaches known as expectant management, watchful waiting, or active surveillance.

Active surveillance or watchful waiting 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. Prostate biopsies may be done as well to see if the cancer is becoming more aggressive. If there is a change in your test results, your doctor would then talk to you about treatment options.
With active surveillance, your cancer will be carefully monitored. Usually this approach includes a doctor visit with a PSA blood test and DRE about every 3 to 6 months. Transrectal ultrasound-guided prostate biopsies may be done every year as well.
Treatment can be started if the cancer seems to be growing or getting worse, based on a rising PSA level or a change in the DRE, ultrasound findings, or biopsy results. 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).

Active surveillance allows the patient to be observed for a time, only treating those men whose cancer grows, and so have a serious form of the cancer. This lets men with a less serious cancer avoid the side effects of a treatment that might not have helped them live longer.

An approach such as this may be recommended if your cancer is not causing any symptoms, is expected to grow slowly (based on a low Gleason score, i.e., 6), and is small and contained within the prostate. This type of approach is not likely to be a good option if you have a fast-growing cancer (for example, a high Gleason score, >8) or if the cancer is likely to have spread outside the prostate (based on PSA levels). 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.
Watchful waiting is also an option for older men who have other co-morbid conditions such as heart disease, diabetes, or another cancer that has been previously treated. A rule of thumb is that if a man has a life expectancy of less than 10 years and has a low grade prostate cancer, then watchful waiting would certainly be suggestion.

Active surveillance is a reasonable option 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.
So far there are no randomized studies comparing active surveillance to treatments such as surgery or radiation therapy. Some early studies of active surveillance (in men who are good candidates) have shown that only about a quarter of the men need to go on to definitive treatment with radiation or surgery.

Bottom Line: Prostate cancer is usually a slow growing tumor that affects millions of American men. One consideration for an older man, with a low Gleason score, and no symptoms from the prostate cancer would be watchful waiting. Each man with prostate cancer needs to have a discussion with his doctor to decide which treatment is best in his situation.

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