If you have an elevated PSA and your doctor gives you a prostate cancer diagnosis, watchful waiting (or active monitoring) is just as effective as surgery or radiation.
Decline of early prostate cancer diagnoses
The declining rate of diagnosis of early prostate cancer has actually contributed to a continuing controversy over the disease.
In 2012 the U.S. Preventive Services Task Force recommended against digital rectal exams are no longer recommended either.
Since then, diagnoses of early prostate cancer in American men aged 50 and older dropped by 19 percent between 2011 and 2012 and by another 6 percent the following year.
“Because prostate cancer often grows slowly, the panel said, screening finds many tumors that might never have harmed the patient,” wrote Denise Grady. “But they are treated anyway. As a result, it concluded, testing saves few lives and leads too many men into unneeded surgery or radiation, which often leaves them impotent and incontinent.”
Watchful waiting for prostate cancer
Some men, told the pros and cons, decide against having any PSA screening, opting instead for watchful waiting (or active surveillance). But some doctors follow a protocol of regular PSA tests at predetermined intervals, believing that having the PSA test, even as an imperfect gauge, is better than nothing at all.
If your PSA numbers are up, your doctor might suggest a biopsy, which can cause undue stress (surgery or radiation that can lead to incontinence or impotence) when you’re facing a slow growing cancer.
Men who chose watchful waiting had the same small risk of dying of prostate cancer over the following 10 years as men who underwent surgery to remove the prostate or have radiation.
“Virtually no one had died from prostate cancer,” says Mark Litwin, MD, chair of urology at the David Geffen School of Medicine at UCLA. “That is a really striking finding: All three groups have almost 100 percent surviving. That should give all men pause before pursuing radical treatment for low- or intermediate-risk tumors.”
Still, one urological surgeon calculated that with over 33,000 fewer detected cases of prostate cancer in 2012 compared to 2011, over 1,200 more men would die. Watchful waiting made sense to best-selling author Garth Callaghan, who said “none of the choices seemed particularly attractive to a 43-year-old man.”
He was considering just having the cancer removed, but dreaded the possibility of side effects from surgery or radiation.
“I was completely torn. My previous experience [with illness] was, just get it out of my body,” he said. But after his doctor explained that prostate cancer is overtreated in the United States, “I did a complete 180,” and he and chose active monitoring.
Your preference, your risk
Doctors say that screening should be based on a man’s preferences and individual risk, and that better ways to screen are needed.
Most experts hadn’t expected a decline in PSA tests at all.
“I’m a little surprised,” said Georgetown’s Kenneth Lin, MD, a family medicine physician at Georgetown University School of Medicine. After another panel recommended that women get fewer mammograms and start at a later age, “the rate of mammography barely budged.”
“Lin suspects that many physicians have first-hand experience with patients who have been harmed by PSA screening, and are, therefore, following the American Cancer Society’s recommendation to clearly explain the test’s potential risks and benefits rather than reflexively order it as part of a routine physical,” according to Sharon Begley of STAT.
April 12, 2018
Christopher Nystuen, MD, MBA