Is it Safe to Watch Instead of Treat Prostate Cancer?

Prostate cancer watchful waiting and active surveillance may improve quality of life

(RxWiki News) Once learning they have cancer, most people want to do whatever is necessary to get the disease out of their bodies. In some cases, though, treating the disease may be unnecessary and more harmful than helpful.

New research has concluded that men who are diagnosed with low-risk prostate cancer may not need immediate treatment. 

Instead, observing the disease over time rather than treating it right away may improve a man’s quality of life while reducing healthcare costs. 

"Learn as much as possible about your cancer diagnosis."

This study was led by Julia Hayes, MD, a medical oncologist in the Lank Center for Genitourinary Oncology at Dana-Farber Cancer Center and Massachusetts General Hospital.

According to these researchers, 70 percent of men in the US diagnosed with prostate cancer have low-risk disease, meaning that the cancer is not likely to be aggressive. Of those diagnosed with the disease, less than 6 percent will die from it.

Despite these statistics, more than 90 percent of men undergo immediate treatment with surgical removal of the prostate (radical prostatectomy) or some form of radiation therapy.

An estimated 60 percent of men diagnosed with prostate cancer may not require any therapy in their lifetimes, said Dr. Hayes, who is a senior scientist at Massachusetts General Hospital's Institute for Technology Assessment.

For this study, the researchers developed a mathematical model to evaluate the costs and outcomes of various scenarios involving men aged 65 or 75 at the time of diagnosis with prostate cancer.

There are two major types of observation: "watchful waiting" and active surveillance. 

Active surveillance involves measuring a man’s prostate-specific antigen (PSA) with a blood test every three months. A rectal exam is performed every six months, and a biopsy of the prostate is given once a year, followed by every three years, if the results are negative.

With the watchful waiting approach, the patient is observed without intensive testing. If symptoms appear, the man is treated accordingly.

If either method finds the disease to be aggressive, treatment with surgery and radiation — either intensity-modulated radiation therapy (IMRT) or brachytherapy (seed implants) — can begin.

Prostate cancer treatment can result in loss of bladder and bowel control and sexual dysfunction.  

The researchers evaluated what’s known as quality-adjusted life expectancy, or QALE. This measure looks at the number of years gained as well as the factors that negatively impact quality of life, such as invasive testing, undergoing treatment, complications and course of disease.

Lifetime costs of each strategy were estimated.

Using their own model, the researchers found the following:

  • For men aged 65, watchful waiting offered the most QALE at the lowest cost, delivering two additional months of QALE for $15,374 less.
  • For men aged 75, watchful waiting was most effective and least expensive, providing 6.08 years of QALE for $18,302.
  • Active surveillance delivered two months less QALE in men aged 75 but cost $11,746 more than watchful waiting.
  • In terms of treatment, brachytherapy was the most effective and least expensive therapy for both age groups.

The authors cautioned that the model used was based on a number of assumptions because data regarding treatment outcomes was scarce.

"Compared with treatment after diagnosis, observation is cost-effective for men aged 65 to 75 years under a wide range of clinical scenarios," the authors wrote.

E. David Crawford, MD, professor of surgery, urology and radiation oncology, and head of the Section of Urologic Oncology at the University of Colorado Health Sciences Center in Denver, doesn’t agree with these findings because of the difficulty in characterizing the nature of prostate cancer.

"The challenge is to define low risk prostate cancer based on rather random transrectal biopsies that can miss aggressive and life-threatening cancers," Dr. Crawford told dailyRx News.

"In every other cancer we diagnose, we stage it with PET scans, bone scans, nodal staging and molecular markers to name a few. In prostate cancer, we rely on these biopsies, and 30 percent of men fail because of inaccurate assessment. New markers of aggressive disease such as Myriad's Prolaris or Genomic Health’s OncoDx will add some more certainty, but we still may need to do more biopsies," said Dr. Crawford, who was not involved in the study.

Findings from this study were published June 18 in the Annals of Internal Medicine.

Funding for this research was provided by the National Cancer Institute, US Department of Defense, Blue Shield of California Foundation and the Prostate Cancer Foundation.

No conflicts of interest were disclosed.

Review Date: 
June 20, 2013