Are you contemplating ‘watchful waiting’ for your early stage prostate cancer? Does your family practice or internal medicine doctor have all of the details or just the headlines? Sometimes this strategy can be a big gamble. The roll of the dice can lead to no progression of your disease or painful spread of the disease.
The September 14, 2016 issue of the prestigious New England Journal of Medicine published an article that showed that survival at 10 years was nearly identical for men who elected watchful waiting compared to those who had surgery or radiation therapy. Nonetheless, the devil is in the details. The results clearly showed that those men who elected watchful waiting had a higher likelihood of metastasis or spread to the bone compared to those men who underwent surgery or radiation therapy.
“The clinical significance of this finding is that with the use of active monitoring, more men will have metastasis and the side effects of salvage treatment (meaning at least lifelong intermittent androgen deprivation therapy), which are not inconsequential,” wrote Dr. Anthony D’Amico, chief of genitourinary radiation oncology at the Dana-Farber Cancer Institute in Boston.
From my point of view, there are pluses and minuses to watchful waiting. But in Dayton, Ohio many physicians simply read the headlines of the article without carefully looking at the details of watchful waiting. In my experience, few men and their doctors follow the guidelines that have been published concerning watchful waiting.
For example, Dr. Laurence Klotz from Toronto critically analyzed the outcomes of watchful waiting for men with low to intermediate risk prostate cancer. Dr. Klotz reported his findings at the May 2016 meeting of The American Urologic Association. Dr. Klotz found that the risk of prostate cancer death at the 15 year mark was only about 5%. Dr. Klotz protocol is one of the most generous compared to the protocol from Johns Hopkins. In fact, only 20% of men who present with prostate cancer would qualify for the Hopkins protocol compared to 50% in the Toronto protocol.
The Toronto protocol calls for the following for men with Gleason score 6 or lower prostate cancer with so called non-extensive disease or low percent of positive biopsies. The current protocol that Dr. Klotz adopts is:
- Eligibility: Most men with Gleason score 6 prostate cancer or lower, and a PSA less than 15 ng/ML.
- Workup: MR scan and targeted biopsies are done for all men with high-volume Gleason score 6 prostate cancer
- Follow-up: PSA every 6 months
- Confirmatory biopsy or MR scan within 1 year. If the MR is negative and there is a low risk disease, biopsy is optional.
- Repeat MR/biopsy every 3-5 years until age 80.
In my experience in Dayton, Ohio few men have insurance coverage for MR scans and even fewer will submit to repeat biopsies.
So if you elect watchful waiting, you need to know the real risk of recurrence. That is to say, just getting a PSA every 6-12 months will not cut it if you truly want to catch prostate cancer early and avoid spread to bone.
If you have any questions about your prostate cancer, please feel free to call me, Dr. Edward Hughes, at 855-Dayton 1.