Most men who learn they have prostate cancer will be told they have a relatively early stage of the disease. This article is for them. Not because later-stage disease is untreatable, but because men with early prostate cancer must choose among a wide range of different treatment options.
Having options is a good thing, but having to choose is hard. Each choice has its advantages -- and its disadvantages. And once most of these choices are made, there's no going back. Even if other options still remain, they will be affected by the original decision.
Four years ago, Santa gave me the worst Christmas present I'd ever received.
The day after the most joyous holiday of the year, my doctor called and
delivered the news that I had prostate cancer.
Because my dad had prostate cancer decades before, I had been going to a
urologist since I turned 40 to have a PSA [prostate-specific antigen test].
Recently, my PSA had shot up very high, to 29, and the following biopsy
confirmed that I had a highly aggressive tumor. At 50 years old, I faced the
"Of the men today diagnosed with prostate cancer, 90% have localized cancer," says Peter Scardino, MD, chair of the urology department at New York's Memorial Sloan Kettering Cancer Center. "The dilemma they face is, 'What shall I do about this? Should I treat it at all, or is the word cancer scaring me into taking potentially dangerous treatments? It is an agonizing decision."
"You have to be aware of the risks -- and you have to make decisions," says Thomas Keane, MD, associate professor of urology at Emory University School of Medicine, in Atlanta. "The only way you can do that is to get the knowledge in the first place. If you are the kind of patient that doesn't do well with that, you need to sit down and spend a lot of time with your doctor."
To choose among treatment options, a man must know how aggressive the cancer seems to be and if the tumor is localized or if it has spread to the lymph nodes or other parts of the body.
A man with localized prostate cancer has four main treatment options:
Prostate cancer usually takes a long time to go from localized cancer to painful, metastatic disease. For a man in his late 70s or 80s with a non-aggressive tumor, it might be a good idea to do nothing at all except keep track of how the disease is progressing, and to deal with symptoms when and if they arise. This is called "watchful waiting." The idea is to wait until the cancer is serious enough to justify the risks of treatment.
Treating prostate cancer lowers the likelihood of dying from the disease. However, many men who do not receive treatment will not die of prostate cancer, "Roughly two of three men treated with surgery will survive without a detectable PSA [prostate specific antigen], and you see similar results in men who receive other forms of treatment. We just don't know the relative benefit of being treated or not being treated." Scardino says.
What's good about watchful waiting is that it avoids the side effects treatment for early stage cancer. It can also give a patient time to more carefully consider his treatment options.
The downside of watchful waiting it that it can be anxiety-provoking to live with untreated cancer. And there is no way to be sure the cancer won't become incurable.