Aggressive Approach to Low Risk Prostate Cancer Questioned

Men with low risk prostate cancer may be getting unneeded aggressive treatment, says a study reported in the Archives of Internal Medicine.

Low risk is where the level of prostate-specific antigen (PSA) is normal or below normal. PSA is a substance produced by the prostate gland, which may be found in higher amounts in men who have prostate cancer.

Recent evidence has shown that among older men with low risk prostate cancer, it is not the cancer they die from, but another condition. For these men, watchful waiting is probably better than surgery or radiation therapy, say the researchers.

More than 90 percent of prostate cancers are found before the disease has spread to other parts of the body, and these men have a five-year survival rate of almost 100 percent.

Since 1975, the overall survival rate of men with prostate cancer has increased, from 69 percent to almost 99 percent in 2003.

Deciding Treatment a Complex Decision

Lead researcher Dr. Robert S. DiPaola says that it is difficult to know which patient should be in watchful waiting and who should receive treatment.

He says physicians need "further efforts in research to understand who is who, and individualize treatment in a better way." Dr. DiPaola is director of the Cancer Institute of New Jersey.

Understanding more about prostate cancer will enable physicians to make better use of the therapies available, he adds. But on an individual basis, the decision whether to have aggressive treatment or not is complex.

Because the decision may be different "depending on age, aggressiveness of the tumor, the PSA level, this is a call to action that patients need a very informed discussion," says Dr. DiPaola.

For the study, Dr. DiPaola's team collected data on 123,934 men with prostate cancer who were listed in the Surveillance, Epidemiology and End Results (SEER) system.

Among these men, 14 percent had PSA levels at or below 4 nanograms per milliliter, which is normal or below normal. These patients were likely to have low risk cancer, the researchers say.

Although the men had low risk cancer, more than 75 percent of them underwent surgery to remove their prostate or had radiation therapy.

Dr. Anthony D'Amico, chief of radiation oncology at Brigham and Women's Hospital in Boston, says, "What needs to be done is to look at people's risk profile, not just based on the PSA and the kind of cancer that was diagnosed, but also based on their overall health."

"There is no data, to date, to understand the natural history of untreated low-risk, low-PSA, prostate cancer in healthy men in their 60s and 70s whose life expectancy is exceeding 10 to 15 years," he says.

Dr. D'Amico notes that healthy younger men with low risk prostate cancer may opt for aggressive treatment, while older men in poorer health could benefit from active monitoring. "For men 60 and 65 in good health, I think, treatment is warranted," he says.

Are Men Screened Too Much?

For another expert, the problem of overtreatment starts with over-screening.

Dr. Otis Brawley, chief medical officer of the American Cancer Society, says that "there are huge problems with PSA screening." Most men who have prostate cancer will die from some other condition and do not have to have their prostate cancer treated, he says.

There are a lot of uncertainties regarding prostate cancer and prostate cancer screening as to whether it save lives, as to whether it diagnoses the cancers that need to be treated, or the cancers that simply need to be watched, explains Dr. Brawley.

He says that men who are worried about prostate cancer should be screened. "It's okay to get prostate cancer screening," he says, "but realize that prostate cancer screening is not nearly as good, as clearly beneficial, as many people have said."

Always consult your physician for more information.