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Health Journal: Some
patients can avoid prostate-cancer treatment
Tuesday, March 28, 2006
By Tara Parker-Pope, The Wall Street Journal
When Tony Masraff was diagnosed with early stage prostate cancer
seven years ago, his doctor advised surgery. But after doing some
research, he decided the best option was no treatment at all.
Mr. Masraff wasn't giving up. Instead he opted for "watchful
waiting," a little-understood option for men with prostate cancer,
where the cancer is monitored with periodic tests rather than treated
immediately. There's increasing evidence that watchful waiting is a
safe option for 30 percent to 50 percent of men with newly diagnosed
prostate cancer, but most of these men either aren't told about it or
decide to pursue surgery or other aggressive treatment that leaves
them impotent, incontinent or both.
Several cancer centers are now conducting research to determine
which patients are the best candidates for watchful waiting. Last week
University of Texas M.D. Anderson Cancer Center announced a
watchful-waiting study of 650 men that will also try to find molecular
markers to help better predict risk. This summer a multinational trial
called START, supported in part by the U.S. and Canadian National
Cancer Institutes, will start recruiting 2,100 men to evaluate
watchful waiting compared with other treatments.
To be sure, prostate cancer is a potentially deadly disease. But in
many men, the disease is slow-growing with little chance of ever
causing problems. "A lot of patients harbor these small areas" of
cancer that don't pose a threat, says Laurence Klotz, professor of
surgery at the University of Toronto and principle investigator on the
START study. Even so, many patients today "are treated as if they
might have aggressive disease."
While one man in six will be diagnosed with prostate cancer in his
lifetime, only about 1 in 34 men will die from the disease, according
to the American Cancer Society. Although screening appears to be
catching more cancers before they become deadly, it also is finding
cancers that would have never caused harm. "We don't know to what
extent we are over-treating patients," says Jeri Kim, associate
professor in genitourinary oncology at M.D. Anderson. "But we are
probably treating a lot of men who may not need it."
However, the strategy of watching cancer and waiting to see if it
spreads also poses a psychological burden for men, who must walk
around knowing they have untreated cancer. Doctors also have a hard
time "leaving" cancer in a patient. But studies show prostate cancer
causes anxiety for every man, whether or not he opts for watchful
waiting or surgery.
Mr. Masraff said he was frustrated that several doctors never told
him watchful waiting was an option for him, and says he prefers living
with cancer than living with the aftereffects of treatment. "My
quality of life is just too important," he says.
The biggest challenge is determining which patients are the best
candidates for watchful waiting -- also called "active surveillance"
or "expectant management." The strategy means that a man diagnosed
with prostate cancer returns for regular PSA testing and additional
biopsies. Depending on the case, the biopsies could be done every six
to 12 months.
One concern is there isn't a consistent standard for what
constitutes a "good risk" prostate cancer. Some doctors advise
watchful waiting if the PSA score is under 10; others suggest a PSA
below 4. A Gleason score, which measures how aggressive the cancer is,
of 6 or lower is also used to determine risk. Whether a tumor can be
felt in a rectal exam, a man's age and the number of positive biopsies
all factor into the decision.
Another measure called prostate density, a combination of PSA score
and prostate volume measured by ultrasound, is also used. It's
important because sometimes a high PSA score is simply the result of
an enlarged prostate and not necessarily an aggressive cancer.
Watchful waiting is typically advised for men over 60. Often, men
under 60 are discouraged from watchful waiting because they have so
many years left in their lifespan -- giving the cancer time to grow
and cause harm.
Some patients who opt for watchful waiting will still end up
needing treatment. This is recommended when PSA scores continue to
rise or additional biopsies show the cancer was more aggressive than
first thought. A PSA score that doubles in less than three years may
signal a more aggressive cancer.
Watchful-waiting patients who end up needing treatment anyway
haven't compromised their care, the Journal of the National Cancer
Institute reported this month. Researchers at Johns Hopkins Medical
School studied 38 patients who needed surgery after about two years of
watchful waiting, compared with 150 similar patients who opted for
surgery right away. There was no difference in noncurable cancer
between the two groups.
"Most individuals are not comfortable with monitoring because the
physicians and the patients are worried about losing the window of
opportunity for a cure," says Ballantine Carter, professor of urology
and oncology at Johns Hopkins. But if a careful selection process is
used, "there is no reason for a man to rush into any treatment."
Last month the medical journal Urologic Oncology noted that among
about 300 men considered candidates for watchful waiting and studied
by the University of Toronto, 34 percent eventually needed treatment.
But the remaining 66 percent of men who opted for watchful waiting
remained stable and avoided radical treatment.
"It's a huge communication challenge to move beyond this widespread
reaction to the word 'cancer,' " says Dr. Klotz. "We try to educate
men that it doesn't always mean they have a serious disease."
Source: Post-gazette.com
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