Watchful waiting for small, non-aggressive tumors has become far more acceptable nowadays. Guidelines issued this year by the National Comprehensive Cancer Network, a nonprofit alliance of 21 cancer centers, recommend that men with small, early-stage tumors and low PSA levels consider frequent monitoring, consisting of an annual physical exam, annual biopsies, and PSA testing every six months. In men over 65, cancers can be treated only if they progress, whereas younger men may still want to consider treatment. "In men who have a greater than 20-year life expectancy, we don't feel as comfortable leaving those cancers untreated," says Patrick Walsh, professor of urology at Johns Hopkins Hospital, who pioneered the nerve-sparing technique for prostate surgery. "We don't know that any cancer won't spread during that period of time, and a 55-year-old could eventually pay the price by having life-threatening metastases."
Still, every man diagnosed with prostate cancer should ask his doctor whether or not he's a candidate for active monitoring, since Walsh says doctors continue to overtreat prostate cancer. If surgery is the only option, a man should make sure his surgeon has performed the requisite 250 procedures. Walsh, who says he has performed an average of 100 prostatectomies a year during his 45-year career, notes that his patients have a 1 to 2 percent incidence of incontinence after surgery and about a 10 percent incidence of long-term impotence.