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Act? Wait? It can be your choice

Treatment itself can be dangerous. And, scientists now say, it might not be necessary -- even for younger men.

July 03, 2006|Susan Brink | Times Staff Writer

IT was, many physicians would say, the right thing for a man of 53 to do. So Larry Cano had a prostate-specific antigen, or PSA, test. "It was 5.3," says Cano, a film producer from Newport Beach. "They say anything over 4 is noteworthy."

The noteworthy result, followed by a positive biopsy, sent Cano pinballing from surgeon to radiologist and back with what he believes, three years later, was an exaggerated sense of urgency.

He may have been right. Researchers -- and a few doctors -- are beginning to agree: Even many younger men with prostate cancer can afford to wait.

"Most of the time, I tell men that they may need treatment, but they're not going to die," says Mark Scholz, a Marina del Rey oncologist, specializing in prostate cancer. "A lot of men with low-grade cancer may not need treatment for five to 10 years."

Some may never need it.

No one initially told Cano that his prostate cancer was not an emergency, that he had time to talk to men who had been through the same diagnosis, to do his own research, to take a deep breath and think about how he wanted to live the rest of his life. No one told him that he could leave his prostate intact, right where it was, while carefully monitoring his condition -- and that he might be able to do that for quite a long time. Maybe forever.

Cano didn't fit the profile of the traditional candidate for what's called watchful waiting, an option that has become synonymous with doing nothing. That approach has been recommended for older men or those threatened by other diseases.

Men like him -- younger, healthier men diagnosed with earlier stages of cancer -- are typically urged to act quickly. They represent the changing demographic of the disease and, like Cano, often feel lucky to catch it early. Cano even made an appointment for surgery. "I thought, just buck up and get it done," he says.

But then he took some time to think again. He did a lot of reading, weighed risks and benefits, and ultimately decided on a form of waiting that is anything but passive.

What Cano chose represents the newest thinking in the disease, and the approach is so different from watchful waiting that no one calls it that any more. They call it active surveillance.

Three years later, his prostate is still where nature put it, he feels fine, and he has become a diligent student of his medically relevant numbers. So far, his cancer is not progressing.

Theoretically, half of men diagnosed with the disease have caught it early enough to at least try active surveillance. The prostate stays, and the patient and his doctors regularly hover over new test numbers and images, on the alert for any sign of change. But only about 12% of such men go that route.

Cano knows full well that he is trading the treatment risks -- impotence and incontinence -- for the risk of waiting too long and missing the best opportunity to cure his cancer. For his choice to pay off, he has to monitor his condition on a tight schedule, and be ready to act if it changes -- all the while hoping for the good luck of slow-growing cancer cells.

Such monitoring of early disease, increasingly debated in the inner sanctum of medical meetings and on the pages of scientific journals, rarely makes its way to the list of choices offered to patients. In fact, the number of men choosing to wait is going down, according to a federal database, even as the number of younger men with low-risk disease is going up.

No one argues that men with more advanced disease ought to make a treatment decision soon. But the growing number of men who are finding out in their 50s and 60s that they have early-stage prostate cancer are also routinely being urged toward surgery or radiation soon after diagnosis, even though medicine currently offers no way of knowing for sure who needs treatment and who doesn't.

It's little wonder, then, that about 150,000 of the 234,460 men diagnosed with the disease each year move quickly to have surgery, radiation seed implants, or one of a variety of other radiation techniques.

"Of the rest, probably about half get hormone treatments and half get watched," says Scholz, Cano's physician. Those watched are typically elderly or have other life-threatening conditions. And they are watched in the old way. "Too much waiting and not enough watching," says Peter Carroll, urologist at UC San Francisco.

Adding confusion to men's hurried decisions, medical science offers no definitive answers to who is a good candidate for surgery, or who might do better with radiation, because there has never been a head-to-head clinical trial of surgery versus the different forms of radiation.

"Neither side wants to find out the other one is better," says Dr. Stephen Doggett, a Tustin radiologist whose practice consists of providing brachytherapy, the implantation of radiation seeds into the prostate. "No one has ever proven that one is better than the other."

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