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Prostate Cancer Overtreated?

Study Shows ‘Watchful Waiting’ Strategy Not Used Enough

Medically Reviewed by Louise Chang, MD on February 22, 2007

Feb. 22, 2007 (Kissimmee, Fla.) -- Fewer than one in 10 men with early prostate cancer and eligible to choose close observation rather than active treatment opts for that strategy, researchers report.

The findings suggest that many men at low risk of having their cancer spread may be overtreated, researcher Daniel Barocas, MD, of New York-Presbyterian Hospital-Weill Cornell Medical Center in New York, tells WebMD.

The study looked at 1,886 men with prostate cancer.

About 16% had early cancer that was contained within the prostate and at very low risk of spreading -- and therefore were eligible to undergo the strategy of "watchful waiting," which involves close monitoring of the tumor growth.

But only 9% opted for that approach, says Barocas.

The study was presented at the 2007 Prostate Cancer Symposium, co-sponsored by the American Society of Clinical Oncology, the American Society for Therapeutic Radiology, and Oncology, and the Society of Urologic Oncology.

The Watchful Waiting Debate

"To treat" or "not to treat" is one of the most difficult dilemmas facing men with prostate cancer, especially those with a small cancer contained within the prostate and curable.

Because prostate cancer often grows so slowly it may never become life-threatening, many of these men, particularly older men, may die of other causes before the cancer causes a problem.

But in some men, the cancer will spread beyond the prostate without treatment. Then it may no longer be curable.

As a result, there has been a long-running debate in the medical community about the value of treatment to destroy cancer cells versus watchful waiting, also known as active surveillance.

Treatment usually involves surgical removal of the prostate or radiation therapy.

Watchful waiting consists of close monitoring with periodic digital rectal exams, biopsies, and PSA (prostate-specific antigen) blood tests. Rising PSA levels can be a sign of prostate cancer spread in men with early cancer.

Watchful Waiting More Common in Older Men

For the study, the researchers analyzed data from a large, national registry of men treated for prostate cancer.

They found that older men were much more likely to opt for watchful waiting than younger men: Those over age 70 were 26 times more likely to choose the strategy than those younger than 63.

Men with low PSA levels (less than 10) were also more likely to forego active treatment.

But overall, the study suggests watchful waiting may be underutilized, particularly among younger men, Barocas says.

Why would so many men opt for treatment, with its costs and potential side effects, when they may not need it?

Fear and worry, Barocas says. “A new diagnosis of cancer produces anxiety, both in patients and their doctors, which drives them to do something, to seek therapy,” he tells WebMD.

No Single Answer

Eric Klein, MD, head of urologic surgery at The Cleveland Clinic, says it’s more complicated.

For starters, doctors don’t have the tools to predict which men who choose watchful waiting will run into trouble and need treatment down the line, he says.

Then, there’s the poor prognosis if the cancer does spread.

“For men who opt for watchful waiting and do end up needing treatment down the line, there is a 1 in 4 chance the cancer will no longer be curable,” Klein tells WebMD.

Klein says he is still on the fence about the strategy. “Most men do fine for many years. But there is a small subset [that does] progress, and we don’t know who they are.”

Barocas says it’s a decision that men, especially older men, need to discuss with their doctors. “There is no one right answer for everyone.”

Show Sources

SOURCES: 2007 Prostate Cancer Symposium, Kissimmee, Fla., Feb 22-24, 2007. Daniel Barocas, MD, department of urology, New York-Presbyterian Hospital-Weill Cornell Medical Center, New York. Eric Klein, MD, head of urologic surgery, The Cleveland Clinic.

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