Well: Often, Just Watching Prostate Cancer Is Enough

When Eddie Carrillo, a Los Angeles contractor, was found to have prostate cancer at the age of 52, his primary care doctor and his urologist both urged him to have his prostate removed. But after hearing about a ?watchful waiting? program on talk radio, Mr. Carrillo decided to simply monitor his disease rather than treat it.

That was 15 years ago, and Mr. Carrillo, still hale at 67, is glad he did not succumb to pressure to undergo surgery.

?What scared me, I wasn?t ready to do the operation right away,? Mr. Carrillo said. ?I have two uncles with prostate cancer, and I have quite a few friends who have had their prostates taken out. The discomfort level and what they went through afterward ? I didn?t think that was the way I wanted to go.?

This year, about 240,000 men will be given a diagnosis of prostate cancer. Although 81 percent of them will discover the disease at a very early stage, and although prostate cancer usually grows very slowly, most of these men will choose aggressive treatment, opting for removal of the prostate, or radiation treatments that often render them impotent or incontinent ? or both.

But about 10 percent of men choose a different strategy: no treatment at all. The decision to forgo surgery or radiation is controversial, and is often met with resistance from a man?s own doctors and family members.

The strategy is often called ?watchful waiting,? but some experts term it ?active surveillance? or ?expectant management.? In older men, watchful waiting may mean that nothing at all is done; doctors intervene only for pain relief or minor procedures if there are signs the cancer has spread.

In younger men, doctors typically conduct regular blood tests and biopsies to monitor the cancer. The idea is that they may recommend surgery or treatment later if it appears the cancer is aggressive and beginning to spread.

Few men choose watchful waiting and few doctors recommend it, but that may soon change. Last week, a groundbreaking new study showed that men with early-stage disease who opt for watchful waiting are just as likely to survive as men who undergo surgery.

The findings, published in The New England Journal of Medicine, come from a 15-year study of 731 men with early-stage prostate cancer who, surprisingly, had agreed to be randomly assigned to surgery or a program of watchful waiting. The fact that so many men had agreed to leave their treatment to chance is remarkable in itself. But so were the findings.

During the study, the largest of its kind, 52 men, or about 7 percent of the study subjects, died of prostate cancer. There was no statistical difference in the prostate cancer mortality rate or the overall death rate between the groups. Most men survived the disease whether they had surgery or did nothing.

And some men who had surgery died, as did some men who did nothing.

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The study suggests what many doctors have long believed: While most prostate cancers are not life-threatening, a vast majority of men who receive the diagnosis are given aggressive treatments. About 100,000 to 120,000 radical prostatectomy operations are performed in the United States each year.

Dr. Timothy J. Wilt, professor of medicine at University of Minnesota School of Medicine and lead author of the report, said the study should give men more confidence to consider watchful waiting as a viable option after a prostate cancer diagnosis.

?Men have a strong belief that if they are diagnosed with cancer, they will die from the cancer if it?s left untreated, and they believe that treatment will cure them,? said Dr. Wilt. ?This study adds to growing evidence that observation can be a wise and preferred treatment option for the vast majority of men. It allows them to live a similar length of life and avoid death from prostate cancer and avoid the harms of treatment.?

Many men report feeling pressure from both doctors and family members to seek treatment rather than monitor the disease. One 49-year-old man who received his diagnosis three years ago said his doctor did not even give him the option for watchful waiting and discussed only surgery and radiation treatments. (He asked that his name not be published to protect his privacy.)

But after researching his options, he enrolled in a Seattle study of active surveillance, and now undergoes regular biopsies and tests to monitor the cancer.

?The cancer is not going anywhere right now,? he said. ?If I had surgery or radiation right away, I was going to live with it for more than half my adult life. If I wait and it does grow slowly, then I still have a chance for a while at a normal life.?

But the few family members and friends he has told about his diagnosis have not supported his decision. A long-term relationship ended, in part, because he would not seek aggressive treatment, and only recently has his father accepted his decision.

?The thing that strikes me is that there is an assumption that by getting treated you are eliminating risk,? he said. ?That?s just not the case. You can have surgery and still die of prostate cancer. You have risks whatever choice you take, and a lot of it is figuring out what things are important to you.?

Dr. Leonard Marks, a professor of urology at the University of California, Los Angeles, said that both patients and doctors need more education about watchful waiting.

?Ninety percent of men who could qualify for active surveillance are actually being actively treated,? said Dr. Marks. ?It requires a lot of education, a lot of teaching, to understand the concept that not all cancers are the same.?

Source: http://feeds.nytimes.com/click.phdo?i=5b0387f1c7db7cacf67128f8d240e065

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