Rethinking the Wait-and-See Approach to Prostate Cancer

Marc Greenstein Health Guide
  • On December 13th, the Washington Post printed a story called Study Disputes Wait-and-See Approach to Prostate Cancer.

    This is an important article challenging the teaching that “something else will kill you besides your prostate cancer.” In other words, Urologists should re-think how they manage low and intermediate risk elderly patients with newly diagnosed prostate cancer.

    There are multiple options to treat prostate cancer when it is confined to the gland (i.e., it has not spread). These include radical surgery, brachytherapy, external radiation, cryosurgery and hormonal ablation therapy.
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    If a patient was thought to have a life expectancy of greater than 15 years they were recommended a curative treatment option. Younger patients were recommended surgery as a curative option while patients 65 years and older were recommended brachytherapy or radiation therapy.

    Cryosurgery is still considered somewhat experimental as a primary treatment option and hormonal ablation will not cure prostate cancer, it tries to control it.

    On the other hand, if a patient did not have a 15 year life expectancy curative intent was not considered and patients would be offered hormonal therapy or watchful waiting.

    But what if the older patient with co-morbid factors develops prostate cancer? For example, a 79 year male with diabetes and a small stroke 1 year ago develops a Gleason 3+3=6 cancer. His PSA is only 7.4 ng/ml and the biopsy shows one positive core. This man could easily live another 10 years with proper medical care for his diabetes and vascular disease.

    Many urologists would offer this patient hormonal ablation or watchful waiting considering he will probably pass away from another disease before his prostate cancer grows, spreads and kills him. This study suggests that these men should strongly consider therapy with curative intent. Based on this study, the same 79 year-old man is better served with either brachytherapy or external radiation.

    This subject has been debated for the last few years. Many urologists feel that prostate cancer patients are over treated since it is slow growing malignancy. The risks of certain treatment options out-weigh the benefits of curing a “slow growing” cancer. For example, the 79 year old man can be cured of his prostate cancer but develop severe radiation cystitis.

    This study challenges this belief and suggests that men should be treated more aggressively. In the end, the patient has to be informed of his treatment options, risks and benefits so he and his urologist can finalize a treatment plan.
Published On: January 03, 2007