Treat or Wait?
Treat or wait? as more men under 70 are diagnosed with prostate cancer, some wonder if they really need to take action against it.
Health Science
Michael Lasalandra, Globe Correspondent
1347 Words
27 January 2004
The Boston Globe
When Secretary of State Colin Powell was diagnosed late last year with prostate cancer, he chose to undergo surgery to remove the diseased gland. Sen. John F. Kerry made the same decision earlier in the year. Former New York City Mayor Rudy Giuliani, diagnosed in 2000, also chose an aggressive treatment: Radioactive seeds were implanted in his prostate.
But both choices, as well as cryotherapy, another popular treatment that involves freezing the prostate to kill cancerous cells, carry the risk of severe side effects, including impotence and incontinence.
Men over 70 are often counseled to delay treatment of early- stage prostate cancer, because these side effects can be so devastating and the disease is rarely fatal in less than 15 years. Increasingly, men in their 50s and 60s - whose tumors are now caught earlier because of improved testing - are also choosing to live with their cancer rather than treat it aggressively. At least for now.
Instead of surgery, cryotherapy or radiation, these men check their levels of prostate specific antigen or PSA every three to six months, get yearly biopsies and, in many cases, adopt diet and lifestyle changes hoping to keep the slow-growing cancer at bay.
But so-called watchful waiting has its side effects, too. Regular testing is anxiety provoking. For younger men, choosing this option usually means finding the rare doctor who will go along with it. And there's always the risk that while the patient waits, the cancer will spread outside the prostate, making it harder to treat.
"If you do this, you are living outside the realm of normal medicine," said Dr. Glenn J. Bubley, director of genitourinary oncology at the Beth Israel Deaconess Medical Center, and one of a minority of prostate cancer doctors open to watchful waiting for younger men. "It requires close followup and living with ambiguity. Some do well with that and some don't. For some people, the anxiety is too great. They say, `If I have cancer, I want it out.' "
Although the routine use of PSA testing has allowed doctors to catch more prostate cancers at an early stage, it's not clear whether all of those cancers really require treatment.
Most men diagnosed with prostate cancer die of something else. Some may have an "indolent" form of the disease that will not progress and will never cause harm - but doctors can't tell which ones.
"We don't have the technologies that are 100 percent accurate to say your disease is progressing and needs to be treated right now," said Dr. Ballentine Carter, a urologist at Johns Hopkins Hospital in Baltimore.
In a "watchful waiting" study Carter is leading, only about one- quarter of the 250 subjects have required more aggressive treatment since the study began in 1995.
In general, Bubley said: "We're giving therapy to people who don't need it and we know it."
Still, urologists, including Carter, generally recommend aggressive treatment for younger men.
"Unless you are treating it somehow, some way, that cancer is not going to go away," said Dr. John Libertino, chief of urology at the Lahey Clinic in Burlington. "My fear is that it will progress. If some cells get outside the prostate, that's dangerous. We never know when that's going to happen. I think you should intervene whenever you have any kind of cancer."
A Swedish study published in 2002 offers strong research support for aggressive action over watchful waiting - but it is also seriously flawed, according to Bubley.
The research subjects who had surgery were less likely to die of prostate cancer than those who chose watchful waiting. (There were prostate cancer deaths among those who had surgery because the cancer recurs in about 25 percent of patients who have the operation.) The overall death rates were about the same, though, meaning that those who had surgery were just as likely to die - but of something other than prostate cancer.
Besides, the findings are almost meaningless for men diagnosed in recent years, Bubley said, because the subjects were all enrolled before PSA testing was common. As a result, the study included men with all stages of cancer, not just those with the early-stage varieties now seen in 75 percent of current diagnoses.
Complicating the comparison is that most who are holding off on treatment today aren't sitting around doing nothing. They are actively battling their cancers by eating low-fat diets, going on exercise and meditation programs, and taking vitamins and supplements thought to keep their cancers from progressing or, perhaps, even causing them to regress. That's why some prefer to call what they are doing "active surveillance" or "conservative management."
There isn't much evidence that such lifestyle changes after a diagnosis of early-stage prostate cancer will keep it from progressing, according to Robert A. Weinberg, cancer researcher at the Massachusetts Institute of Technology and the Whitehead Institute in Cambridge.
"It could have an effect," he said, but most likely only if the cancer has not yet progressed outside the prostate.
A small study by noted California cardiologist Dean Ornish found that men with early-stage prostate cancer who adhered to his rigid program - a low-fat plant-based diet along with exercise and stress management - reduced their PSA scores by an average of 8 percent in three months.
But there are few other studies showing that low-fat diets can help in the battle with prostate cancer. "It hasn't been rigorously tested," Bubley said.
In addition to lifestyle changes, some doctors now give testosterone-blocking drugs - used for years against advanced prostate cancer - to early-stage patients on an intermittent basis. Side effects, such as low libido and hot flashes, are reversible when treatment stops.
Cam Bishop, a social worker from Reading who was diagnosed last year at age 61, is hoping diet and lifestyle changes will keep his cancer at bay long enough so he can avoid aggressive therapies.
"My urologist said I needed a radical prostatectomy immediately," he said. "But I'm an obstinate old bastard. I got on the Net and studied it as much as I could. I knew I wasn't going to have [a radical prostatectomy]. The cure may be worse than the disease."
Bishop said he found another urologist willing to follow him along. "He had studied Chinese herbal medicine," he said. "He understands that there is more than one way to skin a cat."
A low-fat diet, regular exercise and "cupfuls of supplements" have helped his PSA to drop by about one-quarter over the past year, Bishop said. If it were to go up sharply, he said he would still be loath to consider surgery.
"I would look at some form of hormonal treatment . . . if they don't have something new and better."
SIDEBAR: When waiting makes sense Dr. Jonathan Epstein, a pathologist at Johns Hopkins Hospital, only recommends watchful waiting for older men whose expected lifespans are less than 15 years. Here are the criteria he uses to decide when to recommend delaying aggressive treatment:
- The cancer is stage T1C, meaning it was identified via biopsy because of elevated PSA, but cannot be felt during digital rectal exam.
- It is found in only one or two of 12 biopsy needle cores.
- The cancer makes up less than half of each needle core.
- The Gleason score, which rates tumor aggressiveness, is 6 or under.
- The PSA density, a determination of how much PSA is caused by cancer and how much is caused by an enlarged prostate, is between 10 and 15 percent.
- The percent of "free" PSA, which is more likely to be associated with an enlarged prostate than cancer, makes up more than 15 percent of total PSA.
