GIFFORD-JONES: Waiting to treat prostate cancer?
Doctors have stressed for years it’s vital to treat all cancers early to increase the chance of cure. But one rogue malignancy rarely obeys the rules.
Now, a report in the Canadian Medical Association Journal says, “active surveillance” is increasingly used to treat prostate cancer. The big question is, how many patients want to wait when told they have a malignancy?
But why is this currently a choice? Autopsies show that 50 per cent of men over age 59 have prostate cancer, and three in four over 85. One in seven North Americans will be diagnosed with prostate cancer in their lifetime, yet only one in every 28 men will die of it. Obviously, not all need to be treated.
Why does this happen? It’s because prostate cancer can be as tame as a pussy cat. Many men may die of other diseases never knowing they have this malignancy. However, some prostate cancers act like a raging tiger that kills. How do doctors decide which is which?
Unfortunately, it’s not easy. The PSA test measures the level of a protein in the blood produced by the prostate gland. The higher the level the greater the chance of trouble. But some authorities argue the PSA test should never be done as it can result in needless treatment, with complications such as urinary incontinence and impotence. But if the test has already been ordered and found abnormal, a decision must be made.
The next step involves biopsies of the prostate gland. These are analyzed by a pathologist to evaluate the cellular pattern. He reports what’s called the Gleason Score, of 1 to 10. The higher the number the greater the risk of trouble.
The problem is that neither test is infallible. Consequently, this rogue malignancy has always required the wisdom of Solomon to predict which cancers should be treated. So now what criteria are doctors using when they suggest watchful waiting?
First, several biopsies must show relatively normal-looking cells. Being an older patient is a help as there’s a possibility of death from other medical problems before death from prostate cancer. The prostate gland will also be monitored at regular intervals by rectal exams, more PSA tests, CT scans and possibly repeat biopsies.
At the first sign that the guidelines are changing, then a decision must be made as to the best method of treatment.
I have spent hours reading international reports of the results of active, watchful waiting. The jury is still out. So, both doctors and patients must make the decision of their life when faced with this rogue cancer.
The grim fact is that some patients who decide on watchful waiting will die if the cancer spreads to other organs before treatment is started. But, on the other hand, some will also die prematurely from surgical complications when their life is not threatened by the cancer.
Several years ago a tennis friend, during an annual checkup, had a PSA test done. His level was slightly elevated. But five biopsies of the prostate gland were normal. Then a sixth one revealed a slight change. Since he was 74 years of age these minute microscopic cells might not have killed him for 15 years. So I strongly and repeatedly advised him against surgery. But psychologically, he could not live knowing a few cells were abnormal. A radical prostatectomy was done. He died of a blood clot (pulmonary embolism) as he was walking out of the hospital. It was the result of the surgery and a totally needless death.
It’s been said that “If you’re not confused about prostate cancer, you don’t know what’s going on!” But once diagnosed, a decision must be made.
Some men, with young wives and families, may be unwilling to accept watchful waiting as being too risky. Older ones may prefer to live with the devil they know than face the potential complications of treatment. As one of the experts remarked years ago, “Getting older is invariably fatal, cancer of the prostate only sometimes.”
Remember, this column is only for informational purposes and not intended to treat or cure disease. You must always see your own doctor.
Dr. Ken Walker (Gifford-Jones) is a graduate of University of Toronto and Harvard Medical School. He trained in general surgery at Strong Memorial Hospital, University of Rochester, Montreal General Hospital, McGill University and in gynecology at Harvard. His column is published by 70 Canadian newspapers, as well as internationally. For more information, visit docgiff.com or e-mail firstname.lastname@example.org.