Prostate Cancer's Prognosis
New therapies exist, but men still face a tough call: get treated now, or wait
Some men fall on the cusp—and aren't willing to jeopardize quality of life in order to get cured. When Leonard Norwitz of San Jose, Calif., was diagnosed nine years ago, a urologist had strongly recommended surgery. "He thought we ought to get it when it was small," the clinical social worker recalls. But second opinions convinced Norwitz, now 65, that treatment wasn't imperative. Instead, he joined a clinical trial in which he's using lifestyle changes to attempt to control his tumor's growth. He also gets regular follow-up tests. If one raises a red flag, he plans to receive radiation therapy.
But putting off therapy as Norwitz has done can take nerves of steel. At the Brady Urological Institute at Johns Hopkins University, says research director Robert Getzenberg, about 1 patient in 10 who initially declines curative treatment eventually changes his mind, not for any medical reason but rather to rid himself of the psychological burden of carrying cancer. (An additional 2 of every 10 ultimately get surgery or radiation because their cancer seems to be advancing.)
Watchful ways. Better tests for monitoring tumors might help patients feel more secure in their decisions. Researchers are studying numerous genes and proteins that could become useful biomarkers of a tumor's status. Long-standing clinical tools are also undergoing refinement. For example, for almost two decades doctors have used patients' blood concentrations of a protein called prostate specific antigen to screen for cancer. More recently, they've found that a significant increase over time, or upward velocity, in a cancer patient's PSA hints that his tumor may be growing quickly and becoming more apt to metastasize. PSA velocity is now increasingly being used to differentiate between aggressive and indolent tumors—and to guide treatment decisions accordingly. The National Comprehensive Cancer Network, an alliance of cancer centers, recently decided to include PSA velocity in its clinical guidelines, says radiation oncologist Anthony D'Amico of Brigham and Women's Hospital in Boston. The measurement's emerging importance gives healthy men a reason to have their PSA tested, as the American Urological Association recommends that whites over 50 and African-Americans over 40 do annually. If cancer eventually develops, having a pre-existing record of PSA levels could help a man and his doctor gauge the magnitude of the threat, D'Amico says.
Other variables also factor in treatment decisions. Chiledum Ahaghotu, a urologist at Howard University in Washington, D.C., generally recommends surgery or another aggressive therapy to relatively young and healthy patients, while he would consider watchful waiting an option only for men who have a life expectancy of less than 10 years, because of age or illness.
Robots. Meanwhile, new technologies might trim complication rates, tilting the scales toward treatment. One advance, the robotic surgery system dubbed da Vinci, has taken hospitals by storm. Within the past two years, the number of hospitals worldwide using the $1.5 million device has ballooned from 328 to 656, according to Intuitive Surgical, its California-based manufacturer. Some surgeons favor the new system, which gives them fine control. Using joysticks and a live video feed, they guide the robotic arms through dime-size incisions. Accumulating evidence suggests that robotic surgery, with the right person at the controls, is at least as good as the conventional technique. A review of the scientific evidence, published in February in the International Journal of Clinical Practice, suggests that robotic surgery results in less blood loss, shorter hospital stays, and slightly less post-surgical incontinence than the conventional operation. So far, it has resulted in impotence rates and apparent cure rates similar to those of standard surgery. "We have not been able to identify any disadvantages," says Joseph Smith, a urologist at Vanderbilt University Medical Center in Nashville who has performed some 1,500 robotic prostatectomies and 3,000 standard ones. But the skill of the surgeon is more important than the type of procedure, he adds. He recommends that men find an experienced surgeon they trust and let that doctor decide whether to do the procedure robotically.