In light of these developments, we asked two well-known prostate cancer experts, Peter Scardino, MD, chairman of the department of surgery at Memorial Sloan-Kettering Cancer Center in New York, and Chris Parker, MD, senior lecturer and honorary consultant in clinical oncology at Royal Marsden Hospital in Surrey, England, this question: “When, if ever, is active surveillance the right choice for patients with prostate cancer?” Their answers are below.
Dr. Scardino: Active surveillance (AS) is often a good choice. The right approach, in my view, is to be aggressive diagnostically but conservative therapeutically. When it comes to determining appropriate treatment, we must judge the seriousness of the cancer and its potential for metastasizing and eventually causing death, against the patient’s age, overall health, and potential longevity.
I have some patients in their 50s who are on AS. If, with biopsy and MRI, I can validate that their disease is contained and their PSA is stable, I feel comfortable watching them carefully. Maybe half of them will need treatment in five to seven years, and half of them will go 10-15 years before they need treatment.
But we must be cautious about being too conservative. Especially now, when many men are living into their 80s and 90s, it’s possible to make a mistake by being less aggressive. We can never say with certainty that patients won’t lose anything by waiting. We estimate that if a man waits before undergoing treatment, his chances of being cured drop 1% per year.
Thus, if a man has a 95% chance of being cured today, in 10 years he will have an 85% chance of being cured. The alternative to cure may not be death; it may just mean the patient will need a second course of treatment. But you do take more of a chance by waiting.
Thanks to regular PSA screening, we’re diagnosing more prostate cancers these days. Many of these are very small; some are so early that it’s reasonable to look on them not as actual cancers but as histological in-dicators that early malignant changes are going on. What we have then is a problem with language; we call these areas ‘cancers,’ and it scares people to death. As a result, many men want aggressive treatment when the benefits would actually be extremely small.
Radical surgery and radiation are great forms of treatment if a patient has prostate cancer that’s posing a threat to his health. But for tiny, early cancer, you are trading your worry about a lesion that may never become a problem for the immediate complications of surgery or radiation. It’s important to remember that even the best, most modern techniques of brachytherapy cause about 50% of men to become impotent over five years; radiation can also cause radiation proctitis, strictures, and long-term bowel problems. People also underestimate the morbidity factor of surgery.
Of course, when it comes to deciding on treatment, the patient’s wishes must be taken into serious consideration. Some men to whom I strongly recommend treatment are not willing to undergo it. In that case, I keep them informed if the cancer is becoming more serious. On the other hand, if a patient insists on being treated, and if he fully understands the risks and benefits of treatment, it often makes sense to go ahead. We live in a society in which most people like to solve their problems; many doctors and patients think this way.
There are also legal and financial reasons to treat aggressively. There is always the threat of lawsuits; if you put a patient on AS and his cancer metastasizes, you may be sued. Also, if you do radiation and surgery and bill insurance for it, you’ll get paid. If you do AS, your compensation will be considerably lower. Of course, the patient must make the final decision, but I always tell patients not to base treatment decisions on how the options are framed by the first doctor they see. I think every patient should first seek another opinion from a doctor who will not benefit in any way from whatever treatment he selects.
Over the next five to 10 years we will see a number of new technologies that will allow us to knock out a small amount of prostate tissue. This is focal therapy, and it will enable men with small, early cancers, who are uncomfortable with the idea of waiting, to be treated only at the area of abnormality. Currently, some doctors are treating half the lobe of the prostate with cryotherapy, although it’s probably not an ideal tool because it affects the nerves on that side of the prostate.
But new technologies are coming—such as high-intensity fo-cused ultrasound (HIFU), and photodynamic therapy. The technology I’m most excited about is MRI-guided HIFU. The FDA has already ap-proved a trial at Brigham & Women’s Hospital in Boston that’s using focused ultrasound for uterine fibroids. In the future, this will be used to treat breast, prostate, and other cancers.