Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Is it possible to ignore prostate cancer?

James C. Salwitz, MD
Conditions
November 17, 2012
221 Shares
Share
Tweet
Share

Is it possible to ignore a cancer?  Prostate cancer infests almost 250,000 men in this country each year and will kill 28,000 men in the United States in 2012, over 200,000 around the world.  Many lose their lives “too soon”, dying in their 60s or even their 50s.  Nonetheless, authorities do not recommend the PSA blood test for routine screening of this disease.  How can this make sense?  Partly this has to do with the inadequacy of that blood test and its failure to save lives.  However, the key to “ignoring” prostate cancer is that sometimes it is not the deadly illness we have been lead to believe.

Common diseases such as melanoma, colon cancer or pancreatic cancer are aggressive malignancies. These cancers can be lethal no matter how early they are diagnosed.  For example, Stage 1 lung cancer is fatal more than 50% of the time.  We know that the sooner aggressive cancers are removed the better prognosis. Therefore, patients and doctors attempt to detect these diseases early and treat them immediately.  However, this is not always true for prostate cancer.

Almost 80% of 80-year-old men carry a small amount of prostate cancer. However, 80% of men do not die from this disease, or even develop signs of it in their lifetime.  This suggests that a large portion of prostate cancer is not aggressive and does not threaten life.  This type of prostate cancer may not require treatment at diagnosis, and given the possibility of complications, should not receive immediate therapy. Who are these “lucky” patients and how can we decide who needs treatment and who can be observed?

The concept of “active surveillance,” previously referred to as “watchful waiting,” is not new to cancer medicine.  We have used it for decades to observe low-grade chronic diseases such as slow growing lymphomas or certain smoldering leukemia’s.  These chronic incurable illnesses are often observed without risk to the patient.  Treatment, if needed, can be delayed, perhaps for years.  Curable prostate cancer is somewhat different because while it is clear that you can treat it late and certain patients never need treatment at all, if you treat too late patients can unnecessarily die.

Therefore, if we are going to observe and follow certain patients with known prostate cancer, there must be ways to decide in which patients that can be done safely.  We must find the critical warning signs that it is time to treat.  Like gas in a car, you may ignore the gauge, but when the red warning light flashes it is always time to act.  Active surveillance for prostate cancer requires measures to detect danger and a clear plan of action when the “red warning light” flashes.

Oncologists define good prognosis prostate cancer by three measures.  First, how much cancer is found on biopsy?  Experts believe that if the tumor can be detected only on a biopsy, and can not be felt on exam or if it is confined to less than one-half of one lobe of the prostate, that is less likely to grow.  This is Stage T1c or T2a.

The next factor is aggressiveness of the disease.  This is the “Gleason Score.” When a pathologist studies a prostate cancer biopsy under the microscope, he scores two different areas or “fields.”  In each field, using an internationally standard, he determines a score of aggressiveness from 1 to 5.  He adds these two numbers resulting in a Gleason Score of 2 to 10.  Scores less than 5 are rarely seen, probably because those cancers grow so slowly.  Cancers above 8 are aggressive.  A Gleason Score of 5 or 6 shows a modestly aggressive disease, is reassuring to the doctor, and may be one of those cancers that can be observed without immediate treatment.

Finally, the PSA score has value in predicting aggressiveness and likelihood of recurrence.  If the PSA score, at the time of original diagnosis, is less than 10, it helps less dangerous disease.

Thus, a low PSA combined with a low Gleason score, in the setting of minimal disease, indicate this is a cancer the patient and doctor should consider not treating.  This special situation raises the possibility of avoiding the toxicity and invasiveness of therapy by a plan of active surveillance.

Active surveillance does not mean shaking the hand of the urologist and forgetting about the problem.  It is not really ignoring the threat at all.  Active surveillance requires the patient and doctor to commit to a specific plan to watch the cancer.  This means a PSA and rectal exam every three months.  If the PSA doubles in less than three years, treatment is required.  A repeat prostate biopsy one year after the original diagnosis must be performed in order to confirm that more aggressive disease has not been missed.  If the PSA rises, or the biopsy shows a higher Gleason score, then treatment of the cancer is required, using surgery, radiation and/or hormone manipulation.

“Good” prognosis prostate cancer is an opportunity to take a more measured, sophisticated path toward cancer therapy.  It is not for every patient but preliminary research indicates that 30 – 50% of patients can delay therapy, and that the chance of dying from prostate cancer because of delay appears to be small, although the exact risk awaits the results of ongoing trials.  Especially in the older population, or in patients with other medical problems, waiting to treat can have real benefit.   It requires the decision that one can live with the knowledge they harbor a cancer and to commit to an observation plan.  However, for many patients active surveillance offers the chance to avoid the side effects of invasive cancer therapy and maintain an extra measure of dignity and independence.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

Prev

MKSAP: 38-year-old man is evaluated during a routine health examination

November 17, 2012 Kevin 0
…
Next

The difference between complications and negligence

November 17, 2012 Kevin 0
…

Tagged as: Oncology/Hematology

Post navigation

< Previous Post
MKSAP: 38-year-old man is evaluated during a routine health examination
Next Post >
The difference between complications and negligence

More by James C. Salwitz, MD

  • Each line on the radiology list is a patient’s line in the sand

    James C. Salwitz, MD
  • The broader mission for hospice care

    James C. Salwitz, MD
  • Is the medical profession at its end?

    James C. Salwitz, MD

More in Conditions

  • COVID-19 unleashed an ongoing crisis of delirium in hospitals

    Christina Reppas-Rindlisbacher, MD, Nathan Stall, MD, and Paula Rochon, MD
  • Emergency care nightmare: the urgent need for experienced nurses

    Rachel Basham, RN, CCRN
  • Debating the role of psychiatric assessments in medical decisions

    Christian Youssef & Francisco M. Torres, MD
  • 5 things to know about weight from a bariatric surgeon

    Maria Iliakova, MD
  • Physician autonomy and patient interactions in corporate health care

    Michele Luckenbaugh
  • Vague criteria can lead to misdiagnosis and prison

    L. Joseph Parker, MD
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education
    • Family support is pivotal in the treatment of schizophrenia

      Frank Chen, MD | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
  • Recent Posts

    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education
    • Transforming primary care for physician well-being [PODCAST]

      The Podcast by KevinMD | Podcast
    • COVID-19 unleashed an ongoing crisis of delirium in hospitals

      Christina Reppas-Rindlisbacher, MD, Nathan Stall, MD, and Paula Rochon, MD | Conditions
    • Doctors and disability insurance: Protecting your income

      Amarish Dave, DO | Finance
    • Emergency care nightmare: the urgent need for experienced nurses

      Rachel Basham, RN, CCRN | Conditions
    • Physicians have no autonomy. Here’s how to change that.

      Diane W. Shannon, MD, MPH | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Report: Persistence of Gender Inequalities in Cancer Care, and a Call to Action
  • Cancer Risk in NAFLD Higher With Early Disease Onset
  • FDA Displeased With Companies Purposely Adding Sesame to More Foods
  • COVID Vax Appointment Cancelled? New Shot Rollout Faces Challenges
  • Medical Residents Receive 100+ Job Offer Contacts, Survey Shows

Meeting Coverage

  • New Schizophrenia Treatments Are Coming: Don't Panic
  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education
    • Family support is pivotal in the treatment of schizophrenia

      Frank Chen, MD | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
  • Recent Posts

    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education
    • Transforming primary care for physician well-being [PODCAST]

      The Podcast by KevinMD | Podcast
    • COVID-19 unleashed an ongoing crisis of delirium in hospitals

      Christina Reppas-Rindlisbacher, MD, Nathan Stall, MD, and Paula Rochon, MD | Conditions
    • Doctors and disability insurance: Protecting your income

      Amarish Dave, DO | Finance
    • Emergency care nightmare: the urgent need for experienced nurses

      Rachel Basham, RN, CCRN | Conditions
    • Physicians have no autonomy. Here’s how to change that.

      Diane W. Shannon, MD, MPH | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Is it possible to ignore prostate cancer?
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...