More U.S. Men Holding Off on Prostate Cancer Surgery
Many more American men are now saying no to surgery for low-risk prostate cancer, and choosing to monitor the disease instead, a new study finds.
Over just five years, researchers found, the number of men who opted for monitoring tripled -- from 14 percent of patients in 2010, to 42 percent in 2015.
The shift followed new guidelines advocating "active surveillance" as an option for men with low-risk prostate cancer. That refers to small, slow-growing tumors that are unlikely to progress to the point of threatening a man's life.
Active surveillance involves periodic blood tests and exams, and possibly biopsies, to see if the cancer is progressing. Treatment might eventually be recommended, or it might never be necessary.
Cancer experts said the turning tide is good news.
"In medicine, change generally happens very slowly," said Dr. Len Lichtenfeld, chief medical officer of the American Cancer Society. "So, in my view, this is a very rapid shift we're seeing. I think it's remarkable."
Lichtenfeld, who was not involved in the study, said his "hat is off" to the doctors who've embraced the change.
Prostate cancer is common: U.S. men have about a one-in-nine chance of being diagnosed with the disease, according to the cancer society. However, prostate cancer is often slow-growing and may never progress significantly.
Research has shown that if a man lives long enough, he has a high likelihood of developing a prostate tumor, Lichtenfeld pointed out. Years ago, he explained, many older men unknowingly had the disease -- because it "never impacted them" -- and died of other causes.
But then came the era of prostate-specific antigen (PSA) screening, and the number of U.S. men diagnosed with small prostate tumors shot up. Initially, most of those men underwent surgery to remove the prostate gland.
And that treatment carries risks, including lasting incontinence and sexual dysfunction.
"We were 'curing' a lot of men who didn't need to be cured," Lichtenfeld said.
Now things are changing, said Dr. Brandon Mahal, the lead researcher on the new study.
The point of active surveillance, he said, is to help men with low-risk cancer avoid unnecessary treatment side effects.
"These patients should at least discuss active surveillance with their doctor, and consider it," said Mahal. He is a radiation oncologist at Dana-Farber Cancer Institute/Brigham and Women's Hospital, in Boston.
Lichtenfeld agreed. "Some men will still decide, 'I want that thing out of me,' and opt for surgery. But others will be happy to choose active surveillance," he said.
"What's important," Lichtenfeld added, "is that there's a careful conversation about the options. Don't feel like you have to rush into treatment."
The findings, reported online Feb. 11 in the Journal of the American Medical Association, are based on a government cancer database. It included information on nearly 165,000 U.S. men diagnosed with early-stage prostate cancer that was confined to the gland.
Among men with low-risk cancer, the percentage receiving surgery as their initial treatment dropped from about 47 percent in 2010, to 31 percent in 2015. The rate of radiation therapy declined from 38 percent to just under 27 percent, the findings showed.
By 2015 -- the most recent data available -- 42 percent of those patients were choosing active surveillance. But is that rate "high enough?"
"It's definitely encouraging to see it being used more frequently," said Dr. James Eastham, chief of urology at Memorial Sloan Kettering Cancer Center, in New York City. "But there's room for improvement."
That improvement may be happening: Eastham said it's likely the rate of active surveillance has continued to climb since 2015.
And that's not only because doctors are changing their practice, he noted -- but also because patients are more open to active surveillance. "Patients are becoming more comfortable with it," Eastham said.
According to Mahal, the long-term question remains: How will the shift toward active surveillance ultimately affect men's quality of life and longevity?
Because men can live a long time with low-risk prostate cancer, Lichtenfeld said, it will take "years, if not decades," to find out.
"We don't have all the answers yet," he said.
The American Cancer Society has more on prostate cancer treatment.
SOURCES: Brandon Mahal, M.D., division of radiation oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston; Len Lichtenfeld, M.D., chief medical officer, American Cancer Society, Atlanta; James Eastham, M.D., chief, urology service, Memorial Sloan Kettering Cancer Center, New York City; Feb. 11, 2019, Journal of the American Medical Association, online