Prostate Cancer Treatment: When to Wait

There is an ongoing debate in medicine about whether to treat prostate cancer that is very-low risk to low risk. For men older than 75, who are more likely to die of other causes, the decision is fairly straightforward. But some experts believe that most other men—even if they have low-risk disease—should be treated to eliminate any chance of future cancer progression and possible metastasis.

However, now that large clinical trials have demonstrated the lack of benefit in treating older men with favorable-risk cancer, a growing number of doctors—myself included—believe that a man diagnosed with low-risk cancer over the age of 65 to 70, or any man with serious health issues, should seriously consider surveillance as one option.

During active surveillance, a digital rectal examination, [prostate-specific antigen (PSA) test], and periodic biopsies are used regularly to monitor prostate cancer progression. If these tests ever indicate that cancer is progressing, treatment—surgery or radiation therapy—may be warranted.

A common cancer

Prostate cancer is a very prevalent cancer. Doctors know that most men over age 70 harbor some cancerous cells in the prostate. Because the PSA test is not specific for prostate cancer, many of these malignancies are uncovered when a prostate biopsy is performed for a PSA elevation that is unrelated to cancer. I call this serendipity. We also know from countless studies and autopsy reports that most of these small cancers will not cause harm during the lifetime of the patient.

It has been estimated that from 30 percent to 50 percent of prostate cancers detected today with PSA testing would not have been discovered during the patients’ lifetime if a biopsy had not been performed. Treating these cancers cannot prolong life but only reduce its quality. If we treat every man that we find to have prostate cancer, overtreatment rates will continue to be unacceptable.

An alternative approach is to recognize that carefully selected men can be monitored, and if their cancer changes, treatment can be undertaken at that time. That is the thinking behind active surveillance as it is practiced at Johns Hopkins and other urology centers around the world. This approach is gaining more interest in the medical community because of the realization that prostate cancer is being overtreated.

Cancer fears

Prostate cancer has a long, protracted course in most men. Today, in the United States, with widespread PSA screening of men who are free of any noticeable symptoms, prostate cancer is being detected at an extremely early stage in the natural course of the disease.

When compared to men whose cancers are detected the old fashioned way, without PSA screening, most of the cancers discovered today by PSA are of low to moderate risk and unlikely to result in death from prostate cancer in 10 to 15 years if left untreated among men over the age of 65—especially those with other health problems, such as hypertension and cardiovascular disease.

Still, in the absence of definitive tests that can guarantee a man that his cancer will not progress, most men today—even those whose age gives them a life expectancy of less than 15 years—want a solution to their cancer problem. Fearful that cancer will take their lives, they head off to the hospital or radiation center to undergo treatment for their prostate cancer—even though the risks of treatment far surpass the risks posed by the cancer.

It’s the fear factor at work. Everyone fears cancer, and no one wants to die from it, so most men will take a pass on active surveillance. They want the cancer out (surgery) or stopped in its tracks (radiation).

Benefits of active surveillance:

• The side effects of surgery or radiation therapy can be avoided.

• Small, indolent cancers do not receive needless treatment.

• Quality of life is retained.

Potential disadvantages:

• Increased anxiety due to living with untreated prostate cancer.

• The need for frequent testing, including digital rectal exam, PSA, and biopsy.

• The uncertain possibility that the cancer will progress or metastasize before treatment can begin and the window for cure will be lost.

• If treatment is eventually needed, the cancer might be more difficult to treat later on.

What patients ask

To follow are answers to questions that I regularly get from patients recently diagnosed with prostate cancer who want to know about active surveillance and whether it is a course of action that they should consider.

Q. Who should consider active surveillance for prostate cancer?

A. Active surveillance is an acceptable alternative for carefully selected older men (typically 65 and older) who want to monitor their cancer rather than undergo immediate surgery or radiation. Even though these men have curable disease, they understand that it does not have to be cured right now. Instead they take an alternate course of active surveillance and regular testing, deciding to live with an uncertain future while still maintaining a high quality of life, free from any side effects of cancer surgery or radiation.

Q. Who are the ideal candidates for active surveillance for prostate cancer?

A. There is disagreement among physicians about who are the ideal candidates for surveillance. However, to ensure maximum safety, at Johns Hopkins we recommend this approach mostly for men who have a very-low-risk cancer and are, in general, older than 65.
Johns Hopkins pathologist Dr. Jonathan Epstein originally classified very-low-risk prostate cancers as small (less than 0.5cc) and low grade (Gleason score6 or less) and likely to be present if they have the following features:

• Stage T1c

• PSA density (PSA divided by prostate volume) is below 0.15

• No more than two cores with cancer

• No core with more than 50 percent cancer involvement

Many experts are recommending an MRI (magnetic resonance imaging) of the prostate as an additional means of insuring that no larger more aggressive cancer was missed on a prostate biopsy prior to entering surveillance. However, the value of this is yet to be proven.

A low-risk prostate cancer is defined as:

• Stage T1c or T2a

• A PSA less than10.0 ng/ml

• A Gleason score of 6 or less

Together, very-low-risk and low-risk prostate cancer are referred to as favorable-risk prostate cancer.

I believe that the safest candidates for active surveillance are men with very-low-risk disease—unless an individual’s life expectancy is limited by other health issues, in which case a man’s higher-risk disease may also do well with surveillance. But for a man over age 65 who wishes to avoid treatment, studies show that harm is not likely over 15 years without treatment if favorable-risk prostate cancer is present.

In my practice, men with very-low-risk prostate cancer and a life expectancy of less than 20 years are ideal candidates for surveillance. Those with low-risk prostate cancer who have a life expectancy over 15 years can consider surveillance as one option, while men with a life expectancy below 15 years should consider surveillance as a leading option.

Likewise, surveillance should be the recommended strategy for any man in poor health with favorable-risk prostate cancer and a life expectancy of less than 10 years.

Q. What factors should be considered before deciding on active surveillance for low- risk prostate cancer?

A. If you are considering active surveillance, you should first review all other options carefully and understand their benefits and drawbacks. Understand, too, that active surveillance entails close monitoring by a physician on a regular basis. In the Johns Hopkins program, we monitor men with regular PSA measurements and a digital rectal exam twice yearly, as well as an annual or eighteen-month prostate biopsy up until the age of 75.

It goes without saying that if you decide to be monitored, you must stick to the recommended surveillance schedule. Just as important, active surveillance also requires that a man be able to live with the idea that he has cancer and will require long-term testing.

H. Ballentine Carter, M.D.
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H. Ballentine Carter, M.D.

H. Ballentine Carter, M.D., is professor of urology and oncology and the director of adult urology at the Johns Hopkins University School of Medicine in Baltimore. He has written extensively on the diagnosis and staging of prostate cancer. In particular, he has performed research on the prostate-specific antigen (PSA) test: how results change as men age; the variability of results in men with prostate cancer; and the test’s use in staging, predicting, and managing prostate cancer. Dr. Carter chaired the American Urological Association guideline panel that made recommendations for prostate cancer diagnosis. He leads one of the largest active surveillance programs in the United States to monitor men with prostate cancer who do not need immediate treatment. Results from this program have been used to inform guidelines for the management of men with early prostate cancer. Dr. Carter has had research articles published in a number of publications, including The Journal of Urology, Urology, Cancer Research, The Journal of the American Medical Association (JAMA), the Journal of Clinical Oncology, and the Journal of the National Cancer Institute.