When it come to prostate, watch and wait

When it come to prostate, watch and wait
Dr. William Catalona, director of the prostate cancer program at Northwestern Memorial Hospital, speaks to patient Richard LaVerdiere, Friday, March 19, 2010. LaVerdiere flew in from St. Paul, Minnesota just to continue working with Catalona. LaVerdiere credits the doctor for saving his life, and "would do anything for him." (Alex Garcia, Chicago Tribune)

Five years ago, when he was diagnosed with cancer, Kevin Brick gratefully accepted a doctor's offer to wait and see what happened to the tiny tumor in his prostate gland.

So far, there is no evidence the cancer is growing or becoming more aggressive.

"Everything seems to be going fine," says Brick, 60, whose doctor examines his prostate and administers tests every six months.

The approach is called active surveillance, and for the first time it's being endorsed for large numbers of men by a major medical organization: the National Comprehensive Cancer Network, an alliance of 21 leading cancer centers across the U.S.

In new guidelines, NCCN recommends active surveillance for men deemed to have "very low risk" prostate cancer and a life expectancy of less than 20 years. Also, the organization recommends the strategy if a man's prostate cancer is considered "low risk" and his life expectancy is less than 10 years.

Almost 40 percent of the 192,000 men diagnosed with prostate cancer each year could qualify for active surveillance under those standards, said Dr. James Mohler, chairman of the committee that prepared the guidelines and head of urology at Roswell Park Cancer Institute in Buffalo, N.Y.

NCCN's goal is to identify men likely to have slow-growing tumors and prevent unnecessary treatments that can render them incontinent or impotent.

"We know one in six men will be diagnosed with prostate cancer but only one in 40 men will die of prostate cancer," Mohler said. "It's obvious that we don't need to treat every single man with this condition."

The problem is that "we can't determine which prostate cancers are harmless," said Dr. William Catalona, director of the prostate cancer program at Northwestern University's Robert H. Lurie Comprehensive Cancer Center.

With active surveillance, there's a possibility that an aggressive cancer will be missed and the window for potentially life-saving treatment missed, he said.

By that logic, it's safer to intervene than adopt a "wait and see" strategy. And indeed, most doctors recommend surgery, radiation or other therapies, and more than 90 percent of patients follow their advice.

But there's mounting evidence that active surveillance works without adding to prostate cancer's death toll.

The longest running trial of the strategy is at Johns Hopkins University, where experts have followed 800 men over the past 15 years. To qualify, a man must be at least 65. "We have a very strong bias that a younger man who gets diagnosed with prostate cancer should be treated," said Dr. H. Ballentine Carter, professor of urology at Hopkins.

Men who join the program get a PSA (prostate-specific antigen) blood test and digital rectal exam every six months and a biopsy every year, up to age 75. If signs indicate a cancer is growing or becoming more aggressive, a patient is referred to treatment.

No patients enrolled in the program have died of prostate cancer. Thirty-two percent have undergone medical treatments; 56 percent are still undergoing active surveillance; 2 percent died of other causes; and 10 percent have withdrawn or lost touch with the program.

Similarly, there have been no deaths from prostate cancer among 300 men enrolled in an active surveillance program at Roswell Park Cancer Institute.

More trials of active surveillance are being launched across the country. At NorthShore University Health System in the Chicago suburbs, for example, 70 men age 60 or older have signed up for a new program over the past year. One is Richard Henriksen, 65, whose first wife died of pancreatic cancer five years ago.

"I like the fact that I'm being followed closely and that I'm not being pushed into doing something drastic quickly," he said. "Frankly, I'm pretty conservative when it comes to my health, and surgery is the last thing I want to do."

Assessing prostate cancer risk, key indicators
Very low-risk cancer:
No clinical signs of disease, PSA score of less than 10, normal prostate density, fewer than three cores on biopsy with evidence of cancer, Gleason score (a system of grading prostate cancer tissue) of 6 or less
Low-risk cancer:
PSA score less than 10, Gleason score of 6 or less, no clinical signs or a very small nodule involving one prostate lobe
Source: National Comprehensive Cancer Network
Making informed decisions about prostate screening
For years, communities across the country have hosted health fairs where men can be tested for prostate cancer.
It's a bad idea and should be stopped in many cases, says the American Cancer Society in newly revised guidelines.
Too often, men don't get adequate information about the pros and cons of screening, needed counseling or recommended follow-up care when test results are abnormal, according to the organization.
That's especially true of screening programs in disadvantaged communities, where access to medical care is compromised. But even in better-off communities, men often don't get the information they need to make informed decisions about prostate- specific antigen blood tests.
In a national survey, only 20.6 percent of men said doctors discussed the pros and cons of screening and asked about their preferences, according to a September 2009 report in the Archives of Internal Medicine.
Slightly more than 30 percent of men didn't have conversations with doctors about PSA tests. When these conversations occurred, doctors gave much more emphasis to the benefits of screening (discussed 71.4 percent of the time) than the risks, including incontinence and sexual dysfunction (discussed 32 percent of the time).
The study was based on responses from 375 men who participated in the National Survey of Medical Decisions.
Helping men make informed decisions about screening for prostate cancer is a focus of the new American Cancer Society guidelines. For the first time, they specify that every man should be informed about the "uncertainties, risks and potential benefits of screening" and that "no man should be tested without receiving this information," the organization says.
— J.G.