Prostate Cancer's Prognosis
New therapies exist, but men still face a tough call: get treated now, or wait
By the time Jim Hurley, 54, learned last year that he had early-stage prostate cancer, the disease had already killed his father and struck two brothers. With that family history, the plaster artisan from Springfield, N.J., wasn't about to take chances. For two months, he pored over scientific studies, books, and websites about the cancer. He discussed his situation with doctors, his brothers, and other survivors. A surgeon recommended surgery. A radiation oncologist advocated a form of radiation therapy. But Hurley, concerned that either could leave him impotent or incontinent, settled on a novel technique that attacks cancer with sound waves. He had to drop $23,500 and fly to Toronto to get treated with high-intensity focused ultrasound, or HIFU. (Health officials in Canada and Mexico permit the procedure, but U.S. regulators haven't made a decision on it.) So far, he's pleased with the results.
Hurley may be in the vanguard of a new generation of prostate cancer patients, who are seizing on novel medical options in order to confront the disease without sacrificing quality of life. "Prostate cancer can totally decimate your masculinity," says Jim Kiefert, chairman of the executive committee of Us TOO International, a prostate cancer support and education group, and a survivor of the disease. "For every treatment, you run the risk of impotence and incontinence." To minimize the chances of such problems, some patients are now opting for high-tech therapies such as HIFU and robot-assisted surgery. Others are choosing to forgo curative treatment, instead taking a calculated gamble that they can hold out against the disease.
For some men, trying to hold out is an option because the cancer often isn't lethal. About 1 in 6 American men will be diagnosed with prostate cancer at some point, but only about 1 in 35 men will die of it, according to the American Cancer Society. Other men never suffer symptoms: Between 30 and 40 percent of men who die of causes unrelated to cancer turn out to harbor undiagnosed—and effectively harmless—prostate tumors, autopsy results show.
In a study published in May 2005, more than 90 percent of men with low-grade tumors—those with a so-called Gleason score of less than 5—had not died of prostate cancer within 20 years of diagnosis, despite going untreated. "Because prostate cancer usually grows so slowly, many tiny cancers probably do not need treatment," says study coauthor Peter Albertsen of the University of Connecticut Health Center in Farmington. "These are the men who should consider active surveillance." That treatment strategy, also sometimes called watchful waiting, involves close monitoring of the tumor and a treatment intervention if troubling signs emerge.
Some experts argue that watchful waiting is too often overlooked. "All the evidence points to the fact that many men get treatment they don't need," says Laurence Klotz, chief of urology at Sunnybrook Health Science Centre in Toronto.
Nevertheless, plenty of patients fall into a gray area in which surgery or radiation therapy is potentially lifesaving. A Scandinavian study published the same month found that 8.6 percent of patients who received surgery died from prostate cancer within 10 years, compared with 14.4 percent of those who pursued watchful waiting. (Death rates for men diagnosed today may be lower than those in published studies because screening methods have improved.) A 2006 trial also observed a higher death rate among men who went untreated. "Not all cases of prostate cancer are created equal," says Yu-Ning Wong, a medical oncologist at the 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."