Doc Talk: Not all cases of prostate cancer need to be treated

02/18/2014 12:00 AM

08/08/2014 10:22 AM

Does your localized prostate cancer require treatment? Odds are – no.

This is an exciting time to be a physician practicing urology, and one reason is because of new research demonstrating the best care for men with localized prostate cancer. Prostate cancer is the second-most-common cancer in men in the United States. An estimated one in seven men will be diagnosed with prostate cancer in his lifetime, and the likelihood of being diagnosed increases with age. The American Cancer Society estimates that about 233,000 new cases of prostate cancer will be diagnosed in 2014, and more than 29,000 men will die of the disease this year.

Between 1989 and 1992, the identification of men with prostate cancer increased dramatically because of Prostate Specific Antigen (PSA) testing, and the increase in diagnosis resulted in a decrease in prostate-specific-cancer death over the last two decades. However, urologists now understand that prostate cancer is so common that the vast majority of men have evidence of disease at the time of their death. In fact, 80 percent of men likely have asymptomatic prostate cancer by the time they are 80 years old. They just don’t know it, nor should they be concerned, because they will never be bothered by their disease.

Unfortunately, the pendulum has swung too far. Urologists now know that between 85 and 95 percent of men with PSA screen-detected prostate cancer are overdiagnosed; that is, their cancer will not affect their life span or quality of life; therefore, they will not need treatment. The problem is the identifying the one out of 10 men who will become sick of their disease. It would be more acceptable to treat all cases, including those destined never to cause symptoms, if treatment was inexpensive and without complications. However, radical treatment for prostate cancer with radiation or surgery will likely have a large impact on a man’s lifestyle, such as urinary problems, erectile dysfunction and possibly death, not to mention the substantial expense of the treatment. Ideally, such intervention should be restricted to those who need it to save their lives.

One of the most important aspects of practicing urology, therefore, is to understand which patients don’t need any treatment at all. As a result, urologists from high-volume academic centers are practicing “active surveillance” for prostate cancer. This is a program designed to select men who are thought to have low-risk forms of the disease, such as Gleason 6 – the most commonly diagnosed prostate cancer – and carefully monitor them as an alternative to immediate radiotherapy or surgery.

Patients on active surveillance have their serum PSA levels checked frequently with repeat prostate biopsies performed every two to three years, and conversion to treatment is based on disease progression. In recent studies, thousands of men with a Gleason 6 diagnosis have been watched for decades, with few deaths from cancer. This finding is so dramatic that urologists and pathologists nationwide are now debating if Gleason 6 prostate cancer should even be called a “cancer” anymore. Most urologists now believe that men with Gleason 6 should not be asking “What treatment is best?” but rather, “Do I need to be treated at all?”

In these studies, about 25 percent of men on the protocol progress to a more-aggressive disease over a few years, and when then treated, appear to do just as well as if they received immediate treatment for their disease. These data are compelling, and active surveillance should continue to allow urologists to save lives while limiting overtreatment. In counseling patients, many urologists now emphasize the importance of a man’s personal preferences and concerns. Some men are willing to accept declines in quality of life to be rid of a cancer that has minimal chance of causing harm in their lifetime. Others would rather live with a cancer that will not likely hurt them to maintain their current quality of life. Understanding patients’ specific preferences must now play a large part in the decision to monitor or treat this common disease in men.

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