The 'Watchful Wait' Approach To Prostate Cancer

Since the development of the Prostate-Specific Antigen (PSA) test for prostate cancer, early detection and early treatment has been the norm. Martin Sanda, author of a study in the Journal of Clinical Oncology, says that for some low-risk tumors, "watchful waiting" may be a viable treatment option.

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IRA FLATOW, host:

You're listening to SCIENCE FRIDAY from NPR News. I'm Ira Flatow.

For the rest of the hour, new research about prostate cancer.

If you are a middle-aged man, the common wisdom is to get checked for prostate cancer, and improved testing has made early detection efforts much more successful. But what happens if the test comes back positive? The question becomes what to do? How aggressively should we attack what is usually a slow-growing tumor?

One article published this week in the Journal of Clinical Oncology says that in some cases with certain low-risk types of tumors, there's no significant difference in outcome between men who seek immediate treatment and those who adopt the policy of watchful waiting, perhaps delaying treatment for years. Excuse me.

Joining me now is Martin Sanda. He's associate professor of surgery and urology at Harvard Med School, and director of prostate cancer center at Beth Israel Deaconess Medical Center in Boston.

Welcome to SCIENCE FRIDAY.

Dr. MARTIN SANDA (Director, Prostate Cancer Center, Beth Israel Deaconess Medical Center): Hello, Ira. Thank you for having me.

FLATOW: You're welcome. Your study found that there was no significant difference in outcome between men who had immediate treatment and those who could wait a few years for - on low-risk tumors?

Dr. SANDA: Yeah, that's right. We took a look at a study of over 3,000 men with prostate cancer. We're taking part at a national health study called the health professionals follow-up study.

FLATOW: Mm-hmm.

Dr. SANDA: And over a 15- to 20-year period, about 10 percent of the men who had been diagnosed with prostate cancer took the approach of delaying their treatment, holding off on treatment for at least a year or longer.

And we asked how did those men do in the long run? Were there any adverse effects in terms of higher rate of prostate cancer death, for example, for the men who held off on treatment? And what we found was that at an average follow-up of eight years, and in some cases, 10 or 15 years later, the rate of prostate of cancer does for the men who had held off on treatment, particularly for men who had so-called low-risk tumors - the tumors that are in their very earliest stage, slow growing and very small - men with those tumors by and large survive their cancer whether they went into immediate treatment or whether they decided to hold off and wait and see.

Interestingly, it turned out that out of the men who held off on treatment initially, at 10 or 15 years later, half of those men still had not required treatment. So that really supports the notion that some prostate cancers don't need to be treated necessarily.

FLATOW: Hmm. But how do you know which ones those are?

Dr. SANDA: Well, we have some very useful tests that have been available to prostate cancer doctors for quite a long time. Just simply the microscopic appearance of a prostate cancer on biopsy tells us a lot of information. There's a grading system for prostate cancer called the Gleason score.

FLATOW: Mm-hmm.

Dr. SANDA: And this is really a critical component. It tells us whether the cancer is apt to grow quickly or it's a slower growing variety.

And, interestingly, now in the era of PSA blood test screening for prostate cancer, seems that about a third of the cancers that are diagnoses are really of a slower-growing variety. They have this Gleason score of six or less. And these cancers, we anticipate, take many years to grow, and they don't necessarily pose an immediate danger.

FLATOW: Mm-hmm. So do you think that this is going to - if doctors pay attention to the study, that there will be fewer misdiagnosed cases or overdiagnosed cases requiring surgery?

Dr. SANDA: Well, I think what it really addresses is you have hit the nail on the head, which is a problem of overdiagnosis. And this relates back to PSA blood test. And this test came about 20 years ago now, and it allows these prostate cancers to be diagnosed much earlier than they were able to be diagnosed before. And that's had a major benefit in terms of reducing the number of prostate cancer deaths each year.

So that now, in 2008, 2009, we're seeing about 40 percent fewer prostate cancer deaths than were being seen in 1990 before the effects of the testing really became evident.

But the flip side of the PSA testing, it's really a double-edged sword because the flip side is, on the one hand, we're detecting cancers that are aggressive, that really justify being treated, and we're glad to be able to get after those cancers and eliminate them. But on the other hand, you know, we have this other category of cancers, these slower-growing tumors.

And one of the problems that has been out there in terms of managing these slower growing, low-risk cancers is that there hasn't been a lot of data about - or information - simply what happens if we don't treat these tumors right away. And doctors and patients alike, you know, are understandably a lot at ease with the uncertainty of, well, okay, it may be a slower-growing tumor. It may be a very early stage, but, you know, what can we really expect in terms of the long-term survival if we don't get at this aggressively?

And our findings, by looking at men who were as far as 10 or 15 years out, in this era of PSA screening from having deferred or delay their treatment, hopefully, that'll give some reassurance to patients and doctors who were considering this option of not jumping right to surgery or aggressive treatment.

FLATOW: You know, but people, when they hear - they go back to the doctor and they get that phone call and for that, it says come in and they hear the word cancer, it's, yikes. I need to do…

Dr. SANDA: That's right.

FLATOW: …something right away about this.

Dr. SANDA: That's right. And that's our culture. I mean, after all, 40 years ago, we declared a war on cancer and that must mean that all cancer is bad, and if it's found, it must be stamped out. But, as we've made progress and detected some of these cancers so very early, there really needs to be a whole paradigm shift in terms of how we react as a culture to what cancer means.

And it's - you know, it's a different setting in different scenario. Certainly, there are some cancers that are aggressive and, you know, need to be addressed right away. But on the other hand, that's not always the case. I think, one of the important features to - or approaches to get at the - that knee-jerk reaction, is for doctors to bring up this notion that not all cancers might require treatment, even before the test for the prostate cancer is done -before the prostate biopsy - and in fact, even at the time that the PSA blood test, that screening test is done.

Probably, if we did a better job of introducing, right at the forefront, when discussion with a man first comes up, you know, should you be tested for prostate cancer, it would be prudent to bring up right then and there the notion that, hey, you know, if you wind up being found to have prostate cancer, that doesn't necessarily mean you're going to need to be treated for it. Some cancers need to be treated, and in that setting lives can be saved, but some prostate cancers may not.

FLATOW: That's an interesting idea, to have that talk while you're not in the panic mode, right?

Dr. SANDA: That's exactly right.

FLATOW: To have it before you get the test. And so, then when you hear the results, you won't be in that panic mode, and you can make a more thoughtful decision about what you want to do.

Dr. SANDA: That's exactly right. I think it's a preparation for what the news might mean, and that's going to make it more likely to be able to have an open mind about what the options are going to be.

FLATOW: Well, you have to get that message to the doctors too, don't you, not just the patient?

Dr. SANDA: Certainly. I think that that's certainly the case. And I think that that's been, you know, recognized increasingly over the past five, 10 years. And that's why in this particular study, you know, a substantial portion of the men did not go right into immediate treatment, that doctors are beginning to accept this approach.

But, you know, as a doctor too, you're - it's very hard if a patient - patient's reaction to learning that they have cancer is that they really want to be treated. It can be quite a challenge to convince a man in that situation that…

FLATOW: Yeah.

Dr. SANDA: …they might not need to go that route.

FLATOW: Mm-hmm. 1-800-9898-255. A few phone calls. Let's go to Michael in Boynton Beach, Florida.

Hi, Michael.

MICHAEL (Caller): Hi, there. How are you doing this afternoon?

FLATOW: Hi, there.

MICHAEL: Good. I'd ask my question. I mean, we have now the tool of the PSA and I had - I've had a number of blood tests and I continue to have high PSA. I went for a biopsy. The biopsy is negative. And a year or two later, I still have elevated PSA. How does - how do you recommend the patient to treat that or not treat that?

FLATOW: Yeah. Well, if - you're right. You're having conflicting signals from what you read about PSA and what your test come back.

Dr. SANDA: That's right. That's an excellent question. And this is one of…

MICHAEL: And I do have the physical symptoms of a - BPH - the BPH - BHP?

Dr. SANDA: BPH.

MICHAEL: Yup.

Dr. SANDA: That's right. You know, that's an excellent point. And it speaks to one of the other problems with PSA testing, which is that having an abnormal PSA blood test, screening test does not necessarily mean that a man has prostate cancer.

In fact, in most cases of abnormal PSA, that abnormality, the blood test being high, as the gentleman just described, is more commonly due to non-cancerous enlargement of the prostate or BPH which can cause symptoms of difficulty with urinary flow and bladder emptying and such.

And so, this really has - BPH has no relationship to prostate cancer. And this is why when a PSA blood test comes back abnormal, men should not assume that they have prostate cancer. The next step in that situation is to have a prostate biopsy. And in fact, for men - for most men with elevated or high PSA when they have that prostate biopsy, only a third are found to have prostate cancer. So that's another issue that should be brought to the fore when that test is first done.

FLATOW: PSA, is that not a measurement of just - of inflammation some place in the body, but not specifically?

Dr. SANDA: Oh, PSA - a PSA is actually a - it stands for prostate-specific antigens, so PSA is a protein that's made only by the prostate gland. So - but what happens with PSA is that if there is inflammation in the prostate, as you allude to, or if there's enlargement of the prostate, then the levels of that protein getting into the blood can be elevated just as they are when there is a cancer in the prostate.

FLATOW: So you, as a physician or in general, are not recommending that you don't get this test, but that you learn what all the ramifications of the different results might be.

Dr. SANDA: That's true. I think that the test is certainly useful for - and especially so for men who have a life expectancy of 10, 15 years or longer and who might benefit from treating an aggressive cancer if an aggressive cancer is found. But I think the key to making the test be a better part, a more effective part of our medical care, our general health care, will be to give patients a head's up before that blood test is even done…

FLATOW: Yeah.

Dr. SANDA: …that the implications of an abnormal test or of having prostate cancer for that matter, may be very different than what to expect.

FLATOW: Is there anything for you coming up that you - a follow up to this study?

Dr. SANDA: Well, we hope to look into the quality of life of these folks who went into immediate treatment as compared to those who delay their treatment look in to how satisfied they were with their overall cancer care treatment outcome and where they are now. That's really, I think, a next step in where we want to head with this research.

FLATOW: Mm-hmm. We're talking about a prostate cancer this hour on SCIENCE FRIDAY from NPR News.

Talking with Martin Sanda, associate professor of surgery and urology at the Harvard Medical School, and director of Prostate Care Center at Beth Israel Deaconess in Boston.

I guess this is really just something that - because it is goes on so long and because it is a slow-growing tumor for most people, those people have to just keep watching and talking about it. It's - it's not…

Dr. SANDA: That is true. Yeah. I think for men who do go into watchful-waiting mode and don't go into treatment right away, there's a monitoring process.

FLATOW: Yeah.

Dr. SANDA: So for those men, it's not really a decision to ignore the cancer or to come to back in - if it causes symptoms or something along with those line.

FLATOW: And when you say watchful waiting, how often do you go back to watch or get results or retest?

Dr. SANDA: Generally, we recommend that men have their PSA rechecked a couple of times a year, perhaps every four to six months if they are in a monitoring mode with the cancer, and repeat the biopsy at yearly or every-other-year intervals, sometimes use imaging testing like MRI of the prostate. So there's a variety of different tests that we use to follow a different aspects of the cancer along. And, you know, so it is a process and, you know, and it does lay worry to the men who are…

FLATOW: Yeah.

Dr. SANDA: …you know, who are being followed along.

FLATOW: Dr. Sanda, thank you for taking time to be with us. Good luck to you.

Dr. SANDA: My pleasure.

FLATOW: Have a happy holiday weekend.

Martin Sanda is associate professor of surgery and urology at Harvard Med School and director of Prostate Care Center at Beth Israel Deaconess Medical Center in Boston.

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Study: Prostate Cancer May Be Overtreated

A microscope view of prostate cancer. i i

A PSA test can detect a prostate cancer like this one, but it can't tell which form it is. As a result, physicians order treatment that's unnecessary, but comes with considerable side effects. Visuals Unlimited/Corbis hide caption

itoggle caption Visuals Unlimited/Corbis
A microscope view of prostate cancer.

A PSA test can detect a prostate cancer like this one, but it can't tell which form it is. As a result, physicians order treatment that's unnecessary, but comes with considerable side effects.

Visuals Unlimited/Corbis

A popular blood test for prostate cancer is leading many men to get treated for cancer when the treatment might not make much of a difference, according to a study in the current issue of the Journal of the National Cancer Institute.

The study's conclusions are in agreement with two earlier studies published last spring in the New England Journal of Medicine.

The PSA blood screen was once strongly promoted for all men over the age of 50, because high levels of PSA can indicate the presence of cancer. But a PSA test can't predict if treatment will be effective.

Severe Side-Effects

To come to their conclusion, H. Gilbert Welch of the Dartmouth Institute for Heath Policy and Clinical Practice and Peter C. Albertsen of the University of Connecticut School of Medicine first calculated that 1.3 million "extra" cancers were discovered after the PSA test came into use in the late 1980s.

Then they looked at cancer incidence and survival, estimating that over the years, 56,500 prostate cancer deaths were averted because of the early detection possible with the PSA test. They estimated that for every man whose life was saved by the test, 20 men were diagnosed with prostate cancer.

Surgery, radiation and drugs are often used to treat prostate cancer, but the side effects can be severe: As many as one-third of men treated have some level of impotence or incontinence, or both. The reason so few deaths were averted is because of the variability of prostate cancer.

"Some cancers grow very rapidly and kill, and they may grow so rapidly that screening doesn't really help," Welch says.

By the time they are detectable by screening, they have already spread. Other prostate cancers grow so slowly that a man is likely to die of something else before the cancer gets a chance to kill him.

Findings Pose Challenge

The findings came as no surprise to many prostate cancer researchers, because of the two studies published last spring in the New England Journal of Medicine. One study showed no difference in prostate cancer deaths among a group of men who were screened regularly, as compared to a group of men who were not screened. The other study showed only a slight advantage. This year prostate cancer is expected to kill 27,000 American men.

The findings present a challenge to physicians. There is no point to screening if men aren't going to follow up a positive result with treatment, and with treatment making so little difference, some men may not want to put up with the side effects.

Ian Thompson, head of urology at the University of Texas Health Science Center at San Antonio, says there is really only one choice about screening, and that is to explain the evidence to men, and let them make their own choices. That is the advice of the American Cancer Society and the U.S. Preventive Services Task Force.

"Two different men may look at the evidence, and one man may say a prostate cancer death is something I absolutely want to avoid, therefore I'll have a PSA," he says. "Another man might say that change in my quality of life today is more important to me."

If that man wouldn't go through treatment, then there's no point in testing him, Thompson says.

More Research

The new findings, and the ones from last spring, are sending researchers back to the drawing board.

"When the PSA test was discovered, there was enormous hope that in testing thousands and thousands of men, we'd discover cancers before they became metastatic and took the lives of patients," says Jonathan Simons, who heads the Prostate Cancer Foundation, a nonprofit group that promotes prostate cancer research.

Simons says the new research shows that more work is needed to develop a more accurate prostate cancer test.

"We've asked the PSA test to be a perfect test, and it's not a perfect cancer test," he says. "Until we can do that, we have to offer patients choices."

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