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.
Age is nevertheless important. The average age at diagnosis is about 73, according to a study published this year in the American Journal of Men's Health. Most doctors say robust younger men who are uncomfortable living with cancer should consider aggressive treatment, while older men or men with other health problems may be better off with active surveillance.
Characteristics of the tumor, including its size and apparent aggressiveness, are also key. "It's important for patients to realize that not all cases of prostate cancer are created equal, and that the debate over the role of watchful waiting versus treatment centers around patients with low- and intermediate-risk disease," stresses Yu-Ning Wong, a medical oncologist at Fox Chase Cancer Center in Philadelphia. "Patients with more aggressive [tumors] are at a higher risk of developing metastatic disease and really should strongly consider treatment."
But even in a case where some doctors would favor aggressive treatment to prevent possible metastasis, others might counsel watchful waiting to preserve quality of life. These differing schools of thought reflect a fundamental uncertainty among prostate cancer experts: whether aggressive treatment of early-stage prostate cancer actually extends patients' lives. It's an unnerving state of affairs for patients, and much of the decision comes down to how comfortable a man and his doctor are relying on clinical measurements and interpretative calculations, such as the so-called Gleason score that estimates the likelihood that a given tumor will spread and kill.
Given the uncertainty, how should a patient approach his decision? With patience, suggests Litwin, who urges men to take plenty of time before choosing a treatment. If you want the best care, he says, it's worth it to become familiar with the pros and cons of the various treatments, to get multiple medical opinions, and to be prepared to travel to a first-rate medical center in an urban area. But be wary of agonizing over the wrong details. "Men get so burnt out trying to pick one treatment over another they forget to put the same effort into choosing their provider," he says. "The quality of the provider trumps the type of treatment."