Surgery Or Watchful Waiting: Overtreatment Of Prostate Cancer

Prostate cancer is the second most common type of malignancies in men, after lung cancer only. 18% of men (one out of six) will be diagnosed with prostate cancer during his lifetime. Advanced prostate cancer is a life threatening condition which required serious medical intervention. This usually involves surgical removal of prostate gland, as well as multiple rounds of chemotherapy and radiotherapy. When prostate cancer is found at early stage, the treatment options are not so certain, however.

Mortality from prostate cancer is gradually declining

Statistics for prostate cancer is improving in recent years. Mortality is slowly but surely falling. This reflects several important achievements in the early diagnostics, treatment and management of this condition. Drugs are improving, surgical procedures are getting better. Most importantly, early detection of disease is now a norm rather than exception.

The number of patients diagnosed with prostate cancer grew dramatically in recent years when general routine screening for prostate cancer for men after 40 was introduced in many countries. The commonly used screening test detects the level of Prostate Specific Antigen (PSA) in the blood. PSA is a protein usually produced by the prostate cancer cells, although it can be also excreted by normal cells of prostate gland and its level can be elevated when some other prostate problems such as prostatitis are present. The level of PSA below 4 ng/ml is considered safe and normal. Further, more probing, investigation is needed when this level is exceeded. This usually includes the biopsy of prostate. Biopsy not necessarily confirms the presence of tumor since it may contain the sample of tissue from unaffected part of the gland.

Introduction of PSA blood tests helped to diagnose cancer earlier and led to significant reduction in mortality from this disease (by 25-40%). However, routine PSA testing also created a problem of over-treatment.

What are your options if you are diagnosed with an early stage prostate cancer?

If the presence of tumor is confirmed, should it be removed straight away? The answer to this question used to be “surely, yes” but now it sounds more like “maybe” or even “maybe not”. The article published in Current treatment options in oncology highlights the problem of the prostate cancer over-treatment. Despite high rate of diagnosis (18% of adult men), only 3% of patients actually die as a result of this disease. This means that 15% of patients diagnosed with prostate cancer die from something else while having cancer, and cancer doesn’t play any role it this. Prostate cancer tends to develop very slowly, often over the period of two or three decades.

Active Surveillance Programs Are Now Considered As Best Option For Early Prostate Cancer

Active surveillance programs (also known as watchful waiting) are currently recommended for patients with early stage prostate cancer.

The potential of complications and slow rate of disease development are major reasons why nowadays doctors don’t recommend surgery immediately upon the diagnosis of prostate cancer. If disease is at an early stage, it will not create any problems to the patient for many years to come. Obviously, regular medical checks and constant monitoring of PSA level should be performed. Once the signs of disease progression are observed, surgery can be considered as an option.

Due to the anatomical location of prostate gland, the surgery for prostate cancer used to be a rather difficult and not always successful procedure. Now, with introduction of robotic surgery (robotic-assisted laparoscopic prostatectomy (RALRP), the success rate is much higher. Still, in many cases the side effects of surgery can persist for years.

Choosing active surveillance instead of surgery is not an easy decision for many patients

Patients diagnosed with prostate cancer are often uneasy about leaving it as it is and doing nothing. Despite its advantages, active surveillance is often dismissed by patients facing the treatment decision.

Dutasteride (Avodart) is one of the drugs that have potential to contribute positively on this stage. This is a specific compound capable of decreasing the level of dihydrotestosterone (a derivative of testosterone, male sex hormone) in the body. Prostate cancer is sensitive to the level of dihydrotestosterone. The lowering of this hormone’s level may lead to the reduction of tumor size. Recent clinical trials indicate that dutasteride significantly delays the prostate cancer progression, and thus provides a treatment option for men with localized tumor.

Medical advice for early prostate cancer is changing

Medical regulatory bodies now start to question the wisdom of using the PSA testing systems for screening all patients. U.S. Preventive Service Task Force, for instance, recommends now against this screening. The organization argues that PSA screening may help 1 in 1,000 men to avoid dying from prostate cancer, while 4 to 5 men in 1000 will die from disease even with screening. Complete discontinuation of screening programs for prostate cancer does not look like the right decision, but it is clear that both doctors and patients should not take the higher than normal PSA readings as a signal for aggressive surgical intervention.