Dilemma: choosing prostate surgery or watchful waiting

Written by Simon Crompton

Many men who receive a diagnosisThe process of determining which condition a patient may have. of prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. are faced with a difficult choice: should they have surgery or other treatments to remove the cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body., or wait and see whether the cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. is growing fast enough to threaten their health?

Ironically, the more informed you are when going into this decision-making process, the more difficult the decision is likely to be

This 'treat or don't treat' dilemma is more common with prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. than many other cancers. Why? There are two reasons.

First, many prostate cancers are very slow-growing - known by doctors as 'pussycats'. They may never progress enough to produce symptoms, and endanger life - so there's little point in removing them.

On the other hand, some prostate cancers are 'tigers' - fast growing and aggressive. In many cases, it's very hard for doctors to predict which cancers that currently appear to be in their early stages are going to be the pussycats and which are going to be the tigers.

Why not have treatment to remove the cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. anyway, whichever kind it may turn out to be? Because treatment for prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. is not without its risks.

After surgery to remove the prostate glandAn organ with the ability to make and secrete certain fluids., some men have problems with urinary incontinenceThe involuntary passage of urine or faeces. (dripping or leaking of urine), and some have problems with getting an erectionThe enlarged, rigid state of the penis during sexual arousal.. And since prostate removal doesn't guarantee removal of all the cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. cells anyway, many doctors believe that it is best not to operate until they have evidence that a cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. is of the dangerous variety.

Other treatments such as radiotherapy or hormoneA substance produced by a gland in one part of the body and carried by the blood to the organs or tissues where it has an effect. therapy can also cause unpleasant side-effects. So in cases where the cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. has not spread beyond the prostate glandAn organ with the ability to make and secrete certain fluids. or seems to be in its early stages (what doctors call localised cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body.), doctors sometimes recommend either watchful waiting or active surveillance. These are subtly different:

  • Watchful waiting involves less monitoring and usually revolves around looking out for symptoms that may indicate that the cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. is growing
  • Active surveillance means closely monitoring your prostate A gland that surrounds the urethra near the bladder. It produces a fluid that forms part of the semen. - by testing your PSA levels every few months, by regular digital rectal examinations, and by taking biopsies at intervals agreed with your doctor.

Balancing act

In other words, you the patient and your doctors may have a tricky balancing act to perform - trading off the relative risks and benefits of treating against the relative risks and benefits of not treating.

The weight on either side of the balance will depend on your type of cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body., how far it has progressed, and the personal preferences of you and your doctors.

Ironically, the more informed you are when going into this decision-making process, the more difficult the decision is likely to be.

This is because researchers are continually trying to establish under what circumstances watchful waiting or active surveillance is best, and under what circumstances surgery is best.

The balance of evidence shifts as research reveals more and more about what happens to the men who watch and wait, and what happens to those who are treated.

What research tells us

Generally, research indicates that most older men who are diagnosed with early-stage prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. have a good chance of surviving the disease if a watchful waiting or active surveillance approach is taken.

One large study has indicated that men who choose watchful waiting over radical prostatectomyThe surgical removal of the entire prostate gland. are slightly more likely to die of prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body., but the difference in numbers is small. The men in this study had an average age of 65.

For older men, the current preference tends towards non-treatment.

A study of more than 9,000 men over 70 by the Cancer Research Institute of New Jersey indicates that localised prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. found in older men may be best left untreated, because they are very unlikely to die from this.

Learn more about age and other risk factors in prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body..

One of the most recent studies to be published indicates that cure rates for men who choose active surveillance that involves taking follow-up biopsies are identical to those who choose surgery immediately after diagnosisThe process of determining which condition a patient may have..

But clinical developments keep on changing the equation. The development of robotic and sophisticated keyhole surgeryA type of minimally invasive surgery. techniques have brought with them the prospect of considerably reducing some of the unpleasant side-effects of prostate removal.

For example, data collected by the Henry Ford Health System in the US, which has performed 4,000 robotic prostate removals, shows that continence and potency following surgery were significantly better after robotic surgery than open surgery. For some men with localised prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. who have access to robotic surgery, such figures make the idea of treatment a more appealing prospect.

Waiting isn't easy

Most doctors understand that these are difficult decisions to make, and respect that only you, the patient, know what you can live with.

Knowing that you have cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body., and then deciding to do nothing about it, can be psychologically quite difficult.

Many men choose to have surgery or other active treatment despite the risks because they dislike the idea of living with cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. and feel they have to do something.

Many of the complexities of deciding what to do when localised prostate cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. is diagnosed would be removed if there were a reliable and easy test to distinguish between the pussycats and the tigers.

Researchers around the world are pursuing this Holy Grail, and there are tantalising glimpses of it becoming a reality. For example, scientists from the University of Michigan in America, writing in Nature, say they have identified a group of molecules that is produced by the body in response to more aggressive tumours.

This raises the prospect of a simple urine test to assess prostate cancers, although the researchers say that this is still at least five years away.

Not so far away is the EPCA2 blood test, which researchers hope will distinguish between localised prostate cancers and more aggressive ones. And the PCA3 test has already made it into medical practice as a new geneThe basic unit of genetic material carried on chromosomes.-based test on urine samples.