Prostate cancer: treat or wait?

Today, nine out of 10 men diagnosed with prostate cancer have tumors that are detected at the earliest stage, thanks to more widespread prostate-specific antigen (PSA) testing. These cancers, diagnosed when still confined to the prostate gland, are so small they can only be detected through a biopsy.

Maybe you are one of these men. If so, it’s likely that you are feeling overwhelmed by your diagnosis and all the treatment options for early-stage prostate cancer. You may even be feeling as though your life depends on making a treatment decision as quickly as possible.

Thus, it may surprise you to know that one respectable study indicates that you can take up to one year to evaluate the options before choosing a treatment, and it will not affect your long-term likelihood of remaining cancer-free. In a 2005 study, researchers at Memorial Sloan-Kettering Cancer Center analyzed medical records of 3,149 men with early-stage prostate cancer who underwent a radical prostatectomy within a year of diagnosis. The time the men took to make a treatment decision did not affect likelihood of relapse (measured by a rising PSA level, known medically as a biochemical recurrence). This held true even for men at high risk for relapse, based on their clinical profile.

The emotional impact of cancer can be devastating — there’s no question. But you owe it to yourself to do whatever you need in order to remain calm and take things one step at a time. There is no one-size-fits-all treatment for early-stage prostate cancer. Even the experts do not agree about which men with such cancers should be treated, which treatment method is best — or whether, for some tumors, any treatment is even necessary.

Time to decide

As you evaluate treatment options, think not only about your situation today, but also about where you expect to be in five or 10 years — because chances are, you’ll still be alive. And you need to be sure you would make the same treatment decision five or 10 years from now that you will right now.

Other questions to consider: will you be able to deal with impotence if it occurs? What about incontinence (which is actually the more devastating complication, if you ask most men dealing with it)? How will the possible side effects of treatment affect your relationship with your wife or significant other — and your very sense of self? It is vital to really think about these issues: truly informed patients are often better able to deal with adverse consequences than patients who are uninformed or rush into making a decision.

As you evaluate options, keep in mind that studies show patients do not always mention problems such as incontinence or impotence to their doctors. As a result, when your doctor cites numbers or percentages to convey risk, the numbers may be on the low side. It’s not uncommon for a man to talk with other patients — at a support group or while searching for information — and to hear about higher proportions of people being affected by a particular problem.

Weighing benefits and risks

If you are diagnosed with early-stage prostate cancer, your doctor will make a treatment recommendation based on your “numbers” as well as a mathematical tool known as a nomogram, which can help you and your doctor better assess how extensive your cancer is likely to be and whether it is likely to become active in the future.

However, it is important to remember that clinical studies have not provided any evidence that one treatment is better than another — or that any treatment at all actually prolongs life. Average five-, 10-, and 15-year survival rates are virtually the same for all treatment options in early-stage prostate cancer, including active surveillance. It’s also important to understand that no mathematical model is foolproof, and some men diagnosed with early-stage, locally confined disease will later find out that their cancer was more extensive than originally believed.

The treatment options for early-stage prostate cancer fall into three broad categories: surgery, radiation therapy, and active surveillance.

Radical prostatectomy (surgery). The surgeon removes the prostate and seminal vesicles (saclike glands that release fluid that becomes part of semen). In some cases, pelvic lymph nodes are also sampled. This is most often performed through an abdominal incision; abdominal surgery may also be done with a laparoscope. A third option is the perineal technique, involving an incision in the area between the scrotum and the anus (the perineum). The most common side effects are

• impotence (affecting 30% to 70% of men)
• mild to severe incontinence (2% to 15%).

External beam radiation therapy. After a CT scan constructs a three-dimensional picture of the prostate and seminal vesicles, the radiation oncologist directs rays of high-energy radiation at the prostate tumor and sometimes at nearby lymph nodes. The most common side effects are

• impotence (30% to 70%)
• mild to severe incontinence (1% to 2%).

Brachytherapy. With ultrasound guidance, radioactive “seeds” or pellets are implanted in the prostate itself to irradiate the tumor. The most common side effects are

• impotence (30% to 50%)
• mild to severe incontinence (2%).

Active surveillance. This involves an extended period of monitoring the cancer with regular digital rectal exams, PSA tests, and sometimes repeated prostate biopsies. If tests indicate cancer has become active, treatment options are offered. The major risk of active surveillance is that the cancer could become active during the period of surveillance, potentially making prognosis worse.

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