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From: Alex on 28 Mar 2006 20:02
From the Wall Street Journal, March 28, 2006:

Doctors Seek to Identify Which Patients Can Avoid Prostate-Cancer Treatment


Several cancer centers are now conducting research to determine which
patients are the best candidates for watchful waiting. Last week University
of Texas M.D. Anderson Cancer Center announced a watchful-waiting study of
650 men that will also try to find molecular markers to help better predict
risk. This summer a multinational trial called START, supported in part by
the U.S. and Canadian National Cancer Institutes, will start recruiting
2,100 men to evaluate watchful waiting compared with other treatments.

To be sure, prostate cancer is a potentially deadly disease. But in many
men, the disease is slow-growing with little chance of ever causing
problems. "A lot of patients harbor these small areas" of cancer that don't
pose a threat, says Laurence Klotz, professor of surgery at the University
of Toronto and principle investigator on the START study. Even so, many
patients today "are treated as if they might have aggressive disease."

While one man in six will be diagnosed with prostate cancer in his lifetime,
only about 1 in 34 men will die from the disease, according to the American
Cancer Society. Although screening appears to be catching more cancers
before they become deadly, it also is finding cancers that would have never
caused harm. "We don't know to what extent we are over-treating patients,"
says Jeri Kim, associate professor in genitourinary oncology at M.D.
Anderson. "But we are probably treating a lot of men who may not need it."

However, the strategy of watching cancer and waiting to see if it spreads
also poses a psychological burden for men, who must walk around knowing they
have untreated cancer. Doctors also have a hard time "leaving" cancer in a
patient. But studies show prostate cancer causes anxiety for every man,
whether or not he opts for watchful waiting or surgery.

The biggest challenge is determining which patients are the best candidates
for watchful waiting -- also called "active surveillance" or "expectant
management." The strategy means that a man diagnosed with prostate cancer
returns for regular PSA testing and additional biopsies. Depending on the
case, the biopsies could be done every six to 12 months.

One concern is there isn't a consistent standard for what constitutes a
"good risk" prostate cancer. Some doctors advise watchful waiting if the PSA
score is under 10; others suggest a PSA below 4. A Gleason score, which
measures how aggressive the cancer is, of 6 or lower is also used to
determine risk. Whether a tumor can be felt in a rectal exam, a man's age
and the number of positive biopsies all factor into the decision.


Another measure called prostate density, a combination of PSA score and
prostate volume measured by ultrasound, is also used. It's important because
sometimes a high PSA score is simply the result of an enlarged prostate and
not necessarily an aggressive cancer.

Watchful waiting is typically advised for men over 60. Often, men under 60
are discouraged from watchful waiting because they have so many years left
in their lifespan -- giving the cancer time to grow and cause harm.

Some patients who opt for watchful waiting will still end up needing
treatment. This is recommended when PSA scores continue to rise or
additional biopsies show the cancer was more aggressive than first thought.
A PSA score that doubles in less than three years may signal a more
aggressive cancer.

Watchful-waiting patients who end up needing treatment anyway haven't
compromised their care, the Journal of the National Cancer Institute
reported this month. Researchers at Johns Hopkins Medical School studied 38
patients who needed surgery after about two years of watchful waiting,
compared with 150 similar patients who opted for surgery right away. There
was no difference in noncurable cancer between the two groups.

"Most individuals are not comfortable with monitoring because the physicians
and the patients are worried about losing the window of opportunity for a
cure," says Ballantine Carter, professor of urology and oncology at Johns
Hopkins. But if a careful selection process is used, "there is no reason for
a man to rush into any treatment."

Last month the medical journal Urologic Oncology noted that among about 300
men considered candidates for watchful waiting and studied by the University
of Toronto, 34% eventually needed treatment. But the remaining 66% of men
who opted for watchful waiting remained stable and avoided radical
treatment.




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