There is a wide disparity between the incidence of prostate cancer and mortality. Some autopsy reports of non-prostate cancer deaths suggest that 60% to 70% of older men have prostate cancer, and the vast majority are progression-free. This means that many prostate cancers have been “at peace” with us for a long time and are not life-threatening.
In today’s society, focal prostate cancer is much more likely to be detected clinically because of routine prostate specific antigen (PSA) screening and the widespread availability of prostate puncture biopsies. Patients usually undergo radical prostatectomy, but clinically we find a small number of patients whose postoperative pathology does not reveal prostate cancer cells, which are confined to the very small area that was punctured.
The reality has led the medical community to reflect that early radical prostatectomy does help patient survival, but it also brings with it complications that affect quality of life (e.g., urinary incontinence, erectile dysfunction). In order to prevent overtreatment of prostate cancer, the medical community has proposed two approaches to prostate cancer management, “watchful waiting” and “active surveillance”, based on full respect for the patient’s wishes.
Watch and wait
Watch and wait
A conservative treatment (e.g., endocrine antiandrogen therapy) for patients diagnosed with prostate cancer that is closely monitored and followed until local or systemic symptoms (e.g., difficulty urinating, bone pain) develop.
Clinically, it is usually indicated for patients with prostate cancer who are reluctant or too frail to undergo active treatment. In other words, if the benefits of treatment are much less than “letting the disease run its course,” the family can choose to watch and wait, as long as they understand.
The indications for watchful waiting are as follows:
- Patients with advanced prostate cancer who have a strong personal desire to avoid the adverse effects of treatment and whose concerns about adverse effects are much greater than their expectations of survival.
- Patients with a life expectancy of less than 5 years who are fully informed of but refuse to accept adverse effects from active treatment.
- Patients with clinically early (T1b to T2b), well-differentiated (Gleason score 2 to 4) early-stage prostate cancer with a life expectancy of more than 10 years who have been adequately informed but who have refused treatment.
Active surveillance
Patients with potentially curable prostate cancer who do not immediately undergo active treatment because of concerns about quality of life (e.g., sexual function, urinary incontinence) and surgical risk, but instead choose to be closely followed, with active monitoring of disease progression during follow-up and treatment given when a predetermined threshold of disease progression occurs.
Warren Buffett, the American stock god, announced in April 2012 that he had prostate cancer, clinically diagnosed as early-stage cancer that was “not life-threatening at this time” and for which doctors recommended active surveillance.
The indications for active surveillance are as follows:
- Very low-risk patients with a PSA less than 10ng/ml, Gleason score less than 6, number of positive biopsies less than 3 stitches, and clinical T1c~2a prostate cancer with less than 50% positive tumor per puncture specimen.
- Clinical T1a, incidentally detected prostate cancer by transurethral resection of the prostate, cancer volume less than 5% of the volume of tissue removed, pathology suggestive of well-differentiated or intermediate prostate cancer, younger patients with a life expectancy greater than 10 years.
These “no-treatment” prostate cancer patients are still under close surveillance, including PSA every 3-6 months, isotope bone scan once a year, and puncture biopsy if necessary (to avoid missing high-grade cancer cells). If there is a “windfall” of disease, the appropriate medical interventions need to be followed up.
Related reading: