What conditions are more amenable to watchful waiting?

Watchful waiting has become a term often thought of as an alternative to surgery, radiation, or other interventions for early stage prostate cancer. Watchful waiting is actually a viable option for many other conditions too.

Most Mom’s know that tincture of time with watchful waiting lets their children have the opportunity to recover without intervention for many minor injuries and illnesses without exposing them to the risks associated with antibiotics or other therapeutic interventions we physicians may recommend.

I just read the abstract of an article in the Annals of Surgery suggesting that watchful waiting is a safe option for minimally symptomatic inguinal hernias. The training that I received is accepted dogma: inguinal hernias in persons young and healthy enough to safely have surgery should have hernia repair. This was felt important to avoid the possible much more extensive surgery and risks that can accompany these hernias if they become incarcerated or strangulated (when intra-abdominal organs like the bowel become stuck in the hernia defect with risk of tissue injury and leakage of bowel contents leading to peritonitis and needing major surgery and having risk of infection and death).

The study suggests that these risks when compared to the risks of surgery for minimally symptomatic or asymptomatic inguinal hernias makes watchful waiting an acceptable approach.  Although many patients had surgery later, usually because of pain, there were no fatalities and the authors conclude that watchful waiting is acceptable. This makes me feel much better because I’ve stopped strongly encouraging some men from getting surgery in the last few years because of my anecdotal experiences with post-operative discomfort from the now-standard mesh repairs, and the high recurrence rates with the older non-mesh repairs.

It’s easy to understand how the dogma of “every hernia needs repair” came about.  Admittedly there are really bad cases of complicated hernias left untreated.  The surgical industry benefits from doing surgery, so there was little incentive to look at the issue critically and risk losing business.  Even with post-operative complications like mesh pain, inguinal nerve pain and testicular artery injury and testicular infarction, these can be looked at as the “cost” of prevention of more serious or life threatening complications of “neglected” known hernias.  This study was much needed and is appreciated by me at least.

I posted earlier on overdiagnosis — diagnosis and treatment of a condition that is asymptomatic and which left untreated would be asymptomatic for the duration of a patient’s life. Examples include not just many cases of prostate cancer, but things like small goiters, mildly elevated blood pressure, and certain other cancers including selected cases of breast, thyroid and kidney cancers.

Here is a list of a few conditions where it is reasonable to have detailed discussion with your physician, and to consider watchful waiting if your physician makes a diagnosis and you want to consider watchful waiting as an alternative to immediate treatment:

Mildly elevated cholesterol if you don’t have symptomatic atherosclerotic disease other risk such as a heart attack, stroke or peripheral vascular disease of several other risk factors for these conditions like smoking, high blood pressure or diabetes.

Mildly elevated TSH without symptoms of hypothyroidism.  TSH is a test for underactive thyroid, and is often done in evaluation of many types of symptoms, as well as a screening test in asymptomatic persons.  There is a lack of evidence that treatment of TSH levels less than 10 (normal for TSH varies from by lab, but is around 0.4-5.0)

Warts.  Most skin warts are minimally symptomatic, and are notoriously difficult to eradicate.  Many home and office treatments fail, and some are painful and can lead to scarring.  If a wart does not bother you consider just leaving it alone.  Many warts just go away if you are patient enough.

Mild to moderate heartburn.  I see many patients who have found that medications like omeprazole (Prilosec) give excellent relief of their heartburn symptoms.  It is important to consider the risks of long-term treatment with these proton pump inhibitors (PPI) are not insignificant.  Diminished calcium absorption can lead to bone density loss and risk of fractures, and rebound hyperacidity may make it hard to stop your PPI without worse heartburn than prior to treatment.  This has led many physicians to change from aggressive PPI therapy initially and “step-down” therapy after control of symptoms to using the least potent medications that give at least pretty good symptom relief with escalation of therapy for short periods if or when needed.

Asymptomatic gallstones.  Gallstones are common, and can lead to severe episodes of abdominal pain or complications like pancreatitis or cholecystitis.  In these cases surgical removal of the gall bladder is usually the best approach.  Commonly gallstones are found as an “incidentaloma” (a finding unrelated to the reason for a test and highly likely to be of no concern, but which often makes it hard not to do further diagnostic evaluation) on various types of testing like abdominal ultrasound, CT scan or even plain x-rays. In these circumstances the benefit of cholecystectomy is much less clear, and often watchful waiting is preferable.

Mild depression. Since Prozac and subsequently the long list of SSRI and SNRI medications became available in the late 1970’s the treatment of depression became much more tolerable. This has led us to be much more willing to use medications to treat even mild cases of suspected depression.  Other options like exercise, psychotherapy, and just watchful waiting may be better options for non-suicidal and highly functioning persons with mild clinical depression.

The list could be much longer, but, in general, early and aggressive treatment of highly symptomatic or more serious conditions is usually best. On the other hand watchful waiting may be better for asymptomatic and less severe conditions.

Edward Pullen is a family physician who blogs at DrPullen.com.

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