Important information from Johns Hopkins in honor of Prostate Awareness Month.
As a subscriber to Prostate Disorders Health Alerts, you know how important it is to remain vigilant about prostate health. Recently, Dr. H. Ballentine Carter and a team of prominent Johns Hopkins scientists concluded a study on the subject of expectant management and prostate cancer. The study is the subject of an article in our Health After 50 newsletter. Here is the article in its entirety.
When Watchful Waiting Is the Right Choice for Prostate Cancer
Prostate cancer is considered one of the most treatable cancers — detected at an early stage in up to 80% of cases, often slow growing, and typically curable if it is diagnosed before it has spread outside the prostate gland. In fact, some tumors may never become life threatening, even without treatment. Yet because physicians can’t tell which prostate cancers will be aggressive and prone to spread, a certain number of men are treated unnecessarily for prostate cancers that might not have posed significant health risks.
Expectant management, also called watchful waiting, involves delaying surgery or radiation along with regular monitoring of the man’s condition. And it is a treatment option for men with less aggressive prostate cancer; however, doctors and patients are often reluctant to opt for it, afraid of losing the opportunity for cure by allowing the prostate cancer time to spread.
But a recent study at Johns Hopkins has discovered that for some men newly diagnosed with prostate cancer, watchful waiting may not compromise the opportunity for a cure. The study, which looked at men enrolled in the university’s expectant management program from 1995 to 2005, has researchers optimistic about the use of watchful waiting for a select group of low-risk prostate cancer patients.
H. Ballentine Carter, M.D., Professor of Urology and Oncology at the Johns Hopkins School of Medicine and lead author of the study, estimates that overall, perhaps 30% of newly diagnosed men could be managed with watchful waiting.
Who Is a Candidate?
In general, expectant management is considered an option for small, low-grade cancers.
Staging determines the size of the tumor and how far it has spread. T1 tumors are confined to the prostate and are too small to be felt during a digital rectal exam (DRE). The T1 stage is divided into three smaller stages. T1c tumors are the most common stage today. They include those tumors detected through prostate-specific antigen (PSA) testing. (T1a and T1b tumors are found incidentally, rather than through PSA testing.)
Cancer grade, or Gleason score, describes how aggressive the cancer appears to be.
All of the men who delayed surgery in the Hopkins’ study had:
- stage T1c cancer;
- a Gleason score of 6 or less;
- a PSA density of 0.15 or less;
- cancer presence in no more than two cores (tissue samples taken during a biopsy);
- no more than 50% of any core involved with cancer.
In the results, published in the Journal of the National Cancer Institute, 38 patients who delayed surgery for up to two years showed no greater risk of incurable cancer than 150 similar patients who had surgery immediately after their diagnosis.
Says Dr. Carter, “I believe the most appropriate candidates for expectant management at this point are those with the features above. For men who have a limited life expectancy, expectant management may be appropriate for some men with stage T2 disease [the tumor can be felt during DRE].”
Beyond Grades and Stages
Age is an important consideration in watchful waiting. Delaying treatment for prostate cancer is certainly least risky for men over 70 with small tumors; most, Dr. Carter feels, will not benefit from intervention. In fact, in some watchful waiting programs, men over the age of 75 are regularly monitored but go without annual biopsies.
Younger men, however, are likely to live long enough for their prostate cancers to become life threatening. “Men younger than 65 are at greater risk with watchful waiting, and for most we don’t encourage it,” says Dr. Carter. “However, if a younger man chooses this approach, we respect his decisions and monitor him as carefully as possible.”
The other key factor is the patient’s own comfort level. The decision to choose watchful waiting is often a difficult one. For some men, the knowledge that they have prostate cancer—and a curable form of it, no less—makes watchful waiting seem unbearable: Without treatment, they feel, they would simply be too anxious about the disease worsening or about the possibility of losing the opportunity for cure. For others, the idea of delaying the possible after effects of surgery or radiation (such as impotence or incontinence), coupled with the reassurance of frequent monitoring, makes it worthwhile to wait.
When to Stop Waiting
Some men who choose watchful waiting will go on to require more aggressive treatment. Therefore, patients are strictly monitored with an eye to changes that prompt more aggressive intervention. Monitoring includes semiannual DREs, semiannual screenings of both total and free PSA, and annual prostate biopsies.
Signals to move on to surgery or radiation include a change in PSA velocity (the speed with which PSA levels rise), biopsy results showing a Gleason score of 7 or more, more than two core samples involved with cancer, or more than 50% of any one sample involved. Any of these changes suggest that the prostate cancer has become more aggressive or has spread. Between monitoring tests, any change in the patient’s condition—such as blood in the urine, difficulty urinating, or new pain—also signals a need for intervention. In addition, patients themselves sometimes decide that they no longer wish to wait and request treatment.
In the Future
Dr. Carter’s team is studying tissue samples from their patients, looking at a number of factors—biomarkers, genetic influences, and lifestyle considerations—to determine what puts patients at risk for more aggressive disease during expectant management. The hope, says Dr. Carter, “is that research will reveal a group of biomarkers that doctors can look at to predict disease progression when the disease is still curable.”
