Treating Low-Grade Prostate Cancer: What's the Rush?

A diagnosis of prostate cancer is understandably frightening. It's also understandable that the first thought may be to get rid of the offending cancer as soon as possible. You should know, however, that the slow growth of prostate cancers allows plenty of time to consider all the treatment options carefully. A new study reported widely in the media has highlighted the benefits of another option.

The possibility of prostate cancer is usually signaled by an elevated level of prostate-specific antigen (PSA) detected in a blood test or a lump in the prostate found during a digital rectal exam. If the PSA level is high, most men then agree to undergo a needle biopsy to determine whether prostate cancer could be the cause.

If a man's biopsy is positive for cancer, he faces a difficult decision. There are two options for active treatment of prostate cancer. One is surgical removal of the prostate (radical prostatectomy). The other option, radiation therapy, is performed either with external beam radiation or by implantation of tiny radioactive pellets into the prostate (brachytherapy).

A third option, referred to as "watchful waiting," is not followed often enough by men with low-grade prostate cancer, especially those age 70 and older.

Watchful waiting entails regular doctor visits to check for increases in PSA and for periodic prostate biopsies. This option is sometimes referred to as "temporarily deferred treatment" because surgical or radiation treatment can be the next step at any time if the cancer worsens.

The study examined the treatment given to 24,405 men diagnosed with lower-risk prostate cancer. Within one year of diagnosis, 10 percent of these men were treated with radical prostatectomy and 45 percent received radiation therapy. The authors of this report argue that all of these men were overtreated and should instead have adopted watchful waiting for their cancer.

The authors argue that watchful waiting should be the option of choice for men 70 years of age or older with low-grade or moderate-grade prostate cancer. They base their conclusions on previous studies that show men with low- and even moderate-grade prostate cancer who are at least 70 years old are more likely to die of causes other than prostate cancer over the subsequent 20 years. They also conclude that watchful waiting is the appropriate approach for younger men with low-grade cancer.

Prostatectomy and radiation treatment are not only costly but are also associated with possible long-term complications like urinary incontinence and impotence. My brother-in-law suffered both of these complications in the two years after his radical prostatectomy before he died in his mid-60s of an unrelated cause. Although his prostate cancer was low-grade, he simply could not live with the uncertainty of deferring surgery.

On the other hand, active treatment is the preferred option for men of any age with high-grade cancer and for men younger than 65 with moderate-grade cancer. Studies have shown that when these men are treated with radical prostatectomy, they survive longer than those followed with watchful waiting.

Remember, prostate cancer grows slowly. Take time to talk with your urologist about the suitability of active treatment versus watchful waiting in your case. If you decide to pursue active treatment, be sure to consult a radiologist, too, so that you are informed about the risks and benefits of radical prostatectomy versus radiation therapy.


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