After Prostate Cancer Diagnosis, Weigh the Options
For men, a diagnosis of prostate cancer prompts a thicket of difficult decisions. Aggressive action against these tumors extends life span for some patients, but side effects such as impotence and incontinence can take a heavy toll on their quality of life. Other men do best with no invasive treatment at all. In choosing from among myriad treatments, doctors and patients typically work collaboratively to weigh a man's age, his medical history, the tumor's severity, and other personal factors. The list continues to grow. This month, for example, research published in the online version of Cancer suggests it may behoove people to take their ethnicity into account as well.
The most common treatments include surgery to remove the tumor, radiation to kill it, or "watchful waiting." The watchful approach, also called active surveillance, involves frequent monitoring of the tumor, using blood tests and rectal exams, in lieu of aggressive efforts to eradicate it.
In America, the majority of patients—some 72 percent—pass over active surveillance for more aggressive therapy. Mark Litwin, a urologist at UCLA, says this speaks to an American penchant for quick, definitive fixes. But there's also evidence that suggests an aggressive approach pays off. A study published last year, for example, found that men undergoing aggressive treatment were 30 percent less likely to die during the following year than men who did not.
However, there are side effects of treatment to consider. Surgery can slice the nerves and muscles that control erections and urination, while radiation therapy can damage the same tissues. The National Cancer Institute's Prostate Cancer Outcomes Study, an ongoing nationwide study initiated in 1994, found that five years after surgery, 15 percent of surgery patients and 4 percent of radiotherapy patients were incontinent and 79 percent and 63 percent, respectively, reported impotence. (Some of those problems, presumably, were due to the men's advancing age and not their treatment.) While better on both those counts, radiotherapy caused bowel urgency or painful hemorrhoids 9 percent more often than did surgery. And some studies suggest that surgery is particularly effective at clearing cancer. Refinements to surgical techniques and the advent of new forms of radiation therapy may have improved complications rates since the 1,187 men in the NCI study received their treatments. But treatment complications remain a major disincentive to aggressive therapy.
Prostate cancer is usually a slow-growing disease, which means that many men who have a tumor will nevertheless die from something else, before the tumor spreads and becomes dangerous. Selecting the right treatment, therefore, requires considering both how quickly a particular tumor might kill and how much longer the patient, if cancer free, could expect to live.
Predicting the cancer's move is not easy. "People say, 'The cancer will do this. The cancer will do that.' Cancer does whatever it wants," says Cy Stein of Montefiore-Einstein Cancer Center in New York City. Stein, a medical oncologist, thinks that even a small risk that a tumor will spread can make aggressive treatment worth it for many patients. Litwin, in contrast, argues that doctors need to treat discerningly, rather than simply treating most men aggressively. "The risk of dying of prostate cancer is low, no matter what age you are," he says.