Archive for the ‘watchful waiting’ Category

Treating Prostate Cancer By Close Monitoring or ActiveSurveillance

November 25, 2016

Prostate cancer is the most common cancer in older men and second most common cause of death due to cancer in men over the age of 50.  This year more than 180,000 men will be diagnosed with prostate cancer and more than 30,000 men will die of this disease.  There are multiple treatment options for prostate cancer including surgery, radiation, hormone therapy and now there’s a new option: watchful waiting or active surveillance.  Active surveillance means no treatment but careful monitoring with regular digital rectal exams, PSA testing, and possible other tests and\or imaging studies.  This blog is intended to help men who have received a diagnosis of prostate cancer to help guide them in the decision of active surveillance or more aggressive standard treatment options.

What you need to know

The prostate gland is a walnut-sized organ at the base the bladder and surrounds the urethra or the tube in the penis that transports urine from the bladder to the outside of the body.  The prostate gland’s function is to make the fluid that mixes with the sperm and provides the sperm with nourishment to help fertilize an egg and start the process of conception.

For the first part of a man’s life the prostate gland provides pleasure and enjoyment.  After age 50 for reasons not entirely known, the prostate gland starts to grow and compresses the tube or the urethra and produces difficulty with urination.  Again, for reasons not entirely known the prostate cells grow uncontrollably and this results in prostate cancer.

Prostate cancer is a very common as one in seven American men will develop prostate cancer.

There are two tests used to detect prostate cancer: 1) the digital rectal exam and 2) the PSA or prostate specific antigen test.  PSA is a protein made by the prostate gland.  An increased level of PSA can be a sign of prostate cancer but an elevation is also seen in men with prostate gland infections and benign enlargement of the prostate gland.

Active surveillance is now considered an acceptable management option in certain men with prostate cancer.  Active surveillance is a type of close follow up. In addition to the PSA and digital rectal exam, a repeat biopsy may be indicated.  A biopsy test called a fusion-guided biopsy is one of these newer tests that combines the MRI with real-time ultrasound images of the prostate.  Genomic tests are another development for prostate cancer assessment.  These tests look at the DNA of the cancer to decide if the cancer is stable or growing.  If any of these tests indicate that the cancer is growing, you may require additional treatment.

At the present time there is no universal agreement about how often the tests should be done for men who are participating in active surveillance.  Patients who are at low risk, that is have a low PSA and a biopsy that reveals a reasonably favorable pathology report, then he can have his PSA check every six months.  It is also common to have a repeat biopsy 12-18 months after the diagnosis.

Candidates for Active Surveillance

Men with early stage prostate cancer that is confined to the prostate gland are the best candidates for active surveillance.  Also, good candidates are men without symptoms and have prostate cancer that is slow growing.  Finally, older men with serious other medical problems which may interfere with treatment are potential active surveillance candidates.

The benefits of active surveillance is that it is low cost, safe, and has no side effects.  Men are able to maintain day-to-day quality of life and not have any of the complications of treatment such as impotence\ED or urinary incontinence.  The risk is that men can become complement and not follow up as often as they should and that the cancer can grow and become more aggressive.

Bottom Line:  Prostate cancer is a common problem in middle age and older men.  Most men if they live long enough will develop prostate cancer.  However, most men with the diagnosis of prostate cancer will die with the cancer and not from it.  My best advice is to have a conversation with your doctor and see if active surveillance is right for you and your cancer.

Prostate Cancer: A New Test To Determine if Watchful Waiting is Appropriate

October 10, 2014

Prostate cancer affects 1 in 6 American men and causes over 25,000 deaths per year, making prostate cancer the second most common cause of death due to cancer in men (first is lung cancer).

Men who have a biopsy that is positive for prostate cancer are confronted with a decision regarding treatment. If the man has a life expectancy of greater than 10 years, he would be a candidate for surgical removal of the prostate gland, radiation therapy, or even a program of watchful waiting or referred to as active surveillance. So what is a man to do with a diagnosis of prostate cancer? Now there is a test, Prolaris, that will help men decide which cancers are aggressive and may require more aggressive treatment, i.e., surgery or radiation, and which cancers are indolent and the men may be candidates for watchful waiting.

Until now the only consideration for men with prostate cancer was the grade of the cancer and the stage of the cancer. However, there are men with low PSA levels and a low grade or Gleason score, who have an aggressive tumor as determined by the Prolaris test and perhaps should consider additional treatment.

How is the Prolaris test performed?

The doctor can submit your original prostate biopsy for analysis and this will look at several genetic markers to determine the Prolaris score. No additional blood test or biopsy is required. The Prolaris test provides an accurate assessment of the aggressiveness of your tumor.

The Prolaris score provides information that helps you and your doctor make the best treatment decision. For example a low risk Ca and low Prolaris score, may persuade you to consider watchful waiting and have close follow up with a digital rectal exam and a PSA test every 3-4 months. On the other hand, a high Prolaris score is suggestive of an aggressive tumor and more aggressive treatment may be selected.

Bottom Line: Until now no lab test or imaging study can determine the aggressiveness of your prostate cancer. Now you and your doctor can make a more informed decision about the potential of your cancer to remain slow growing and you would be a candidate for watchful waiting or the prostate cancer is more aggressive and more aggressive therapy is in order.

Prostate Cancer-Watch, Wait, and Not Whither

January 28, 2014

Prostate cancer is the most common cancer in men and the second most common cause of death in men after lung cancer. The diagnosis is made with a PSA blood test and a digital rectal exam and if either of these are abnormal, the man is subjected to a prostate biopsy. Then comes the big decision: does the man proceed to treatment and face the risk of urinary incontinence and\or erectile dysfunction\impotence?

In the past few years there has been a trend towards active surveillance or after receiving the diagnosis of prostate cancer, the man accepts close monitoring with repeated blood tests and possibly repeat prostate biopsies to make certain that the cancer is not progressing or escaping from the prostate and spreading to other organs or structures.

First a comment on screening. Men between the ages of 55 and 69 are those most likely to benefit from screening with a PSA blood test and a digital rectal examination. A man should only be screened after a discussion with his\her physician about the benefits and harms of screening. A new trend is not to treat every man diagnosed with prostate cancer or active surveillance. Not every man qualifies for active surveillance.

Men with a very low risk of cancer progression have a low-grade cancer of the prostate. Prostate cancers are graded from 1-10 and those with a score of 6 or less may be candidates for active surveillance. Men are in the very low risk group if only a few of the biopsies are positive for cancer and that the cancer is not felt on the digital rectal exam.

Men who were on the active surveillance program at John Hopkins School of Medicine had a 2.8% would die of their prostate cancer compared to 1.6% of men who had a very low risk of cancer progression who had surgical removal of their prostate glands. The researches at John Hopkins found that the average increase in life expectancy after surgical removal of the prostate gland was only 1.8 months and that the men on active surveillance would remain free of treatment for an additional 6.4 years as compared to men who had immediate treatment with surgery on their prostate glands.

Bottom Line: Men need to have a discussion with their physicians about the benefits and risks of prostate cancer screening. Men with a life expectancy in excess of 20 years or younger men who have low risk disease may accept the risks of treatment rather than take the chance their cancer will cause harm later. Men with very low risk disease can take comfort that their disease can safely be managed by active surveillance.

Watching The Results On Watchful Waiting For Prostate Cancer

October 29, 2013

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.

Watchful Waiting May Be An Option for Low-Grade Prostate Cancer

June 19, 2011

A recent report coming from research at Johns Hopkins University demonstrated that men with very low-grade prostate cancer may be able to be observed closely for any progression and avoid or delay treatment.  The study included over 700 men with localized prostate cancer that was very low-grade or not very malignant who were followed every six months with PSA testing and a rectal exam and a prostate biopsy every year.  Since 1995 none of the men has died from prostate cancer.  One-third of the men had to undergo subsequent treat five or even 10 years later because their PSA increased for their biopsy showed a more aggressive form of cancer was present in the prostate gland.

Nearly 60 percent of men enrolled were able to defer treatment for 5 years or longer and > 40 percent were able to defer treatment for 10 years or longer. This means they were also able to defer all risks associated with active treatment (incontinence, erectile dysfunction, bowel problems associated with radiation therapy, etc.).

Bottom Line: This study offers good evidence that watchful waiting may be an option for older men diagnosed with a very low-grade prostate cancer.  However, these men must be committed to regular follow up.