The new prostate cancer dilemma

In 2002, after doctors told William Lewis, 61, that he had prostate cancer, his urologist urged him to undergo treatment right away with either surgery or radiation. Lewis, a former government official and economic consultant, wasn’t convinced that aggressive therapy was the best choice, especially since side effects can include impotence and urinary incontinence.

Instead, Mr. Lewis opted for what’s called active surveillance. Active surveillance is a new, proactive monitoring regimen that involves forgoing treatment while doctors keep a close eye on the tumor to make sure it’s not turning dangerous. Surveillance generally involves regular blood tests, rectal exams, and annual biopsies.

Active surveillance differs from the earlier, laissez-faire approach termed watchful waiting, in which treatment is deferred until the cancer actually produces symptoms. Active surveillance is possible because prostate cancer often grows so slowly that it poses little risk to a man’s overall health or life, especially if he’s over 65.

When should a patient be patient?
A recent multi-study review by researchers at the Johns Hopkins University School of Medicine determined that 45% of patients with newly diagnosed prostate cancer qualify for active surveillance. According to Johns Hopkins researcher H. Ballantine Carter, MD, a man should consider an active surveillance program if:
• he has low-risk disease
• his PSA levels are lower than 10 (high levels of PSA, a protein produced by the prostate gland, suggest the presence of cancer)
• his tumor is nonpalpable (meaning it can’t be felt by a doctor during a rectal exam)
• his Gleason score is 6 or less (Gleason score records how many aggressive cancer cells are present).

Pedal to the metal?
When should a man who’s been undergoing active surveillance opt for active treatment? Experts say that surgery or radiation should usually be considered when a man’s PSA level or Gleason score jumps significantly. Dr. Carter notes that the relationship between a man’s PSA level and the size of his prostate should also be considered. “If his PSA level is high and out of proportion to the size of his prostate,” he says, “the patient is more likely to have a higher-grade disease.”

Four years and counting
At this point, William Lewis has been enrolled in an active surveillance program at Johns Hopkins for more than four years, and he has no regrets. “I did my homework, investigated my medical options, and made my choice. I don’t even think about my prostate cancer on most days,” he adds, “only every six months, when I see the doctor and get tested. I still feel active surveillance was absolutely the right thing to do.”