Active Surveillance Treatment Option For Prostate Cancer:

Balancing Watchful Waiting and Wishful Thinking

There is a definite trend towards the down-staging of prostate cancer, in regards to a recent
Journal of Clinical Oncology article. The study, conducted by Dr. Peter Scardino of
Memorial Sloan-Kettering Cancer Center in New York, analyzed more than 12,600 men with
prostate cancer, who had their prostates removed. The study discusses the side effects of
radical treatment for prostate cancer, which in some cases may be slow growing, and
advocates close monitoring of the disease before opting for surgery.

The take-away message of this study shows that radical prostatectomy works well. The study
results determined that 15 years later, only 12 percent had died from cancer. On the other
hand, 38 percent had died from other causes. This conclusion was evidenced by the low
morbidity of screen-detected cancers and also advocated the effectiveness of radical
prostatectomy.

The study, which took place over the course of 1987-2005, paints a radically different picture
than that of today’s patients. In 1985, there was a much higher risk of microscopic spread of
disease. But all of that has changed because of what has been learned over the past 20 years,
with regards to technology and experience, especially in the area of robotics. The open and
laparoscopic surgeries of the past were often high risk and difficult, involving painful
incisions, blood transfusions, infections, extended hospital stays and prolonged use of a
catheter. Radiation as a treatment option was also very popular because it was less invasive.
However, the risk of cancer recurrence was very high.

However, because of technological evolution and surgical expertise, robotic surgery has
become the number one treatment option because it is less invasive than the older modalities.
In the past, the surgeons did not have such a level of magnification, a bloodless field to work
in and often had a higher risk of leaving cancer behind. With robotic surgery, there is less
incidence of rectal bleeding or burning to rectum or bladder, the future risk of secondary
carcinoma is avoided, the cure rate is higher – at nearly 95% - and the side effects of
incontinence and impotence are eliminated. Of course, radiation is still used as salvage route
in the instance of a cancerous recurrence. However, now it is possible to get radiation after
surgery and have a lower morbidity rate.

Another key to the down-staging of prostate cancer is education and public awareness.
Doctors are detecting cases in earlier stages, rendering the disease to be more organ confined.
Therefore with the technological advances, earlier screening, better patient education, the
morbidity rate would be closer to 5%, if a newer study were to incorporate a contemporary
series of robotic surgery patients.

The generalized assumption that some forms of prostate cancer can be slow growing is
inaccurate. Prostate cancer is like the black box of a plane, except you don’t have to crash to
learn valuable information before a tragedy happens. It is impossible for a doctor to know for
sure exactly what is going on in the prostate unless a biopsy is done. Even when a biopsy is
performed, the randomness of the test, in which doctors take and evaluate different range of
cores, still can’t give doctors an accurate picture of the state of cancer. Though it can give
doctors a good idea, the samples could still miss vital tale-telling signs of the type and stage
of cancer.

Every patient should be treated as an individual. In treating the patient as an individual, an

experienced oncologist will know that the disease progresses differently in every patient. By
taking all screening factors into consideration, doctors can then decide what type of cancer
the patient has and what treatment will be most beneficial to them. Prostate cancer case has
an expansive spectrum and there are many different types of prostate cancers, which can
range from low to moderate to aggressive.

This study also illustrated that patients who opted for watchful waiting did not seem to suffer
anxiety and distress from living with ''untreated'' cancer. One must be careful when opting
for active surveillance. This type of watchful waiting can only be successful if the patient
actively partners with his doctor in his treatment. This means seeing a physician regularly
every 3 months, analyzing PSA, DRE and Gleason scores and taking multiple biopsies. One
of the primary surgical benefits would be that the PSA would be undetectable for six weeks,
and then consequently at a zero level for the rest of the patient’s life. Successful prostate
cancer treatment would not only improve quality of life but also lower anxiety and stress.

As stated in the article, “many men undergo aggressive surgery and radiation, and end up
living with the side effects of treatment -- including impotence and incontinence -- for a
cancer that may never have killed them.” But this is no longer the case. By removing the
prostate, the surgeon obtains valuable information, more so than other modalities. They know
the margins, the type of cancer and the lymph nodes for staging purposes. With contemporary
robotic surgery, the cure rate and quality of life higher, because robotic surgery spares the
delicate nerves responsible for continence and sexual function, which make it an ideal choice
for most men.

Watchful waiting may actually be wishful thinking with a disease that is known as the “silent
killer.” Prostate cancer exhibits no symptoms, unlike cancer of the liver or pancreas, in which
patients lose weight, have jaundiced skin and unexplained bleeding. It’s difficult to know
exactly what is going on in prostate, PSAs and Gleason scores fluctuate, and the methods of
biopsy and imaging are sometimes inaccurate and imprecise.

Prostate removal is not for all cancer patients, which is why this study is so important.
Watchful waiting makes sense for some patients, such as older patients who are not
candidates for surgery. Surgery is best for aggressive cancer or patients who are determined
to remove the cancer and get on with their lives. Such is the case with United States Senator
Chris Dodd, who was diagnosed in July with early-stage prostate cancer and is scheduled to
undergo surgery during the Senate's August recess.

When opting for surgery, practice makes perfect. It is important to partner with a skilled and
experienced surgeon who handles a large volume of cases. In the hands of an experienced
surgeon, in centers of excellence such as Memorial Sloane Kettering and Mount Sinai, with
high surgical volumes, the risk death is low. This experience translates to higher success rates
and less risk of a recurrent surgery. Surgery is less invasive and radical, side effects are
lower, quality of life is improved and the cure rate is higher when discovered earlier. With
continuing education, technology and surgical experience, this down-staging trend for
prostate cancer and the prognosis outlook 20 years from now will be even more positive.