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When to Watch: The Complicated Choice of Prostate Cancer

The more we learn about cancer, the more it’s clear that it’s not one disease. Non-Small Cell Lung Cancer (NSCLC), for example, is the most common type of lung cancer, making up 80 to 85 percent of all cases, but even NSCLC can be broken down into multiple types, such as Adenocarcinoma, Squamous cenn carcinoma, large cell carcinoma, or large cell neuroendocrine tumors. In most cases, diagnosing the specific disease type early carries huge benefits. From there, the next steps can go in several different directions, and nothing highlights this varied approach more than prostate cancer.

Understandably, most patients diagnosed with cancer feel the faster they can get treatment, the better. That’s generally true, and the idea of putting off treatment in favor of “keeping an eye” on the disease is counter-intuitive to everything most people believe about cancer. While watching and waiting may seem scarier, new research is suggesting that in some cases, it could be the right move.

A new study called the ProtecT Trials, a massive undertaking as far as these studies go, looked at three different options for prostate cancer patients whose diseases are less aggressive.

“To say that these results were highly anticipated by the medical community is an understatement,” said Neha Vapiwala, MD, an associate professor of Radiation Oncology in the Abramson Cancer Center at the Hospital of the University of Pennsylvania.

Researchers divided more than 1,600 men with localized prostate cancer into three groups: Surgery, Radiation, and Surveillance. After 10 years, there was no significant difference in the overall survival of the patients in each group.

The study also looked at the impact of these treatment approaches on quality of life. Patients who had surgery saw the greatest impact on sexual and urinary function. Patients in the radiotherapy arm of the study reported worse bowel function. But in terms of the level of anxiety and depression that can come with cancer treatment, researchers found the patients were essentially the same across all three groups.

The results of this study aren’t definitive enough to declare a winner, but the findings in the surveillance group are striking. It begs the question of whether or not it makes sense for patients to prioritize deferred or no treatment over immediate treatment that will inevitably come with some significant side effects, both upfront and possibly long-term.

“The first thing to remember is that this is a subset of all prostate cancer patients, with disease that is deemed appropriate for management with any of the three main options: Surgery, radiation, or active surveillance,” Vapiwala said. Her commentary on the findings was published by the American Society of Clinical Oncology.

Vapiwala points out that the patients involved in this study had a generally lower-risk form of prostate cancer. Patients with more aggressive disease and in otherwise good health should receive treatment, as certainly those with high-risk prostate cancer cannot afford to wait.

“People also need to know that this study is not a green light to take a uniformly passive approach to their treatment,” Vapiwala said. “A greater proportion of the patients in the surveillance group of this study did develop metastatic disease compared to the two treatment groups, which is the very outcome one would want to avoid. From that standpoint, this study reminds us that while active surveillance is very reasonable for select patients, we must continue to gather data on its long-term outcomes.”

Vapiwala pointed out two keys to surveillance: Careful selection of the right candidates, and continuous counseling of patients on the potential trade-offs of avoiding upfront treatment with surgery or radiation.

 “Some of these patients have diseases that won’t progress quickly,” Vapiwala said on the first point. “Some may be older when they are diagnosed, and some may be dealing with other more serious illnesses. In these cases, it may make sense to avoid treatment and the side effects that will decrease their quality of life.”

Second, Vapiwala says surveillance cannot be solely patient driven and passive, and doctors should take an active role in counseling their patients about their options.

“We can continue to explore specific features of the patient and his cancer to better predict who will do well with surveillance and who may not,” Vapiwala said. “Investigating the role of genomic tests, advanced imaging capabilities, and other biomarkers of disease aggressiveness will continue to improve our understanding of the different types of prostate cancer, beyond the current tools of PSA and Gleason score.

“For example, why do some ‘low risk’ prostate cancers behave well and others surprisingly poorly? More accurate answers to these questions will guide us on the best choice for a given patient.”

Every cancer is unique, and different disease sites and types present different treatment paths for patients. While early-stage prostate cancer is proving to be less deadly than many other types of cancer, it can still kill. Catching the disease early and talking about the possible treatment options is still the best way forward, even as research into new approaches and innovations continues.       

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