Watchful waiting for prostate cancer
What is watchful waiting. In this technique patients with prostate cancer are monitored to asses whether their prostate cancer is progressing or progressing very slowly. In this case it is safe not to intervene with more aggressive treatments. It is a very reasonable option for some patients. Other names for this management technique are watch & wait and active surveillance. Some clinicians have tried to say there is a subtle difference between the names. For example, some say that active surveillance refers to patients who would go on to have radical treatments such as surgery, brachytherapy or radiotherapy and watchful watching refers to patients who will go on the have non curative treatments such as palliative radiotherapy or hormones.
What is done Men have a consultation asking questions about symptoms (passing water at night, strength or stream etc), a rectal examination and a PSA at regular intervals. If the symptoms are minor and not deteriating, the prostate feels the same and the PSA is not rising then the clinician is usually happy. If the PSA is rising, the rate of rise is calculated - this is called the PSA doubling time (PSAdt). If this is slow then again the clinician is usually happy although this will be discussed with you during the consultation. If it is short, this indicates the disease is on the move and more radical treatments may be offered to you.
Who is eligible for watchful waiting. There are no hard and fast rules but usually the management is suggested as an option in men who have:
Few urinary symptoms
Less aggressive (lower grade) tumours - Gleason 6 and below
Low PSA or rising very slowly if that information is available (long PSA doubling time)
Older or less fit men
Advantages Although radical treatments are generally safe and well tolerated they are not without some risks and side effects. Not undergoing more aggressive treatments will avoid or delay the risk of developing these side effects.
There is a very small chance that the disease can spread form the prostate
whilst waiting although there is little evidence for this. For example the
original evidence for this management was based on a trial by Chodak (et al
1994) who published a phase 2 study of 206 men with stage T1-3 prostate cancer.
Although 84% had PSA progression only
19% required treatment. 11% developed metastatic disease and only 4% died of prostate
cancer. In another trial in
2001 by Richard Choo from Toronto, men with clinical stage T1b-T2b disease with a
Gleason Score < 7, and initial PSA < 15 ng/mg were followed every 3 months.
A repeat biopsy was performed at 18 months.
Indications for radical treatment were PSA progression,
defined as a PSA doubling time < 2 years; histologic
progression, defined as upgrading to Gleason score > 8
on re-biopsy; or clinical progression.
So in summary there is a small risk of the cancer spread under your and your doctors nose but this risk is small and balanced against the advantages of not exposing your self to the side effects and risks of radical treatments
What can you do to help yourself
Further studies have indicate that patients deficient in selenium have a higher chance of developing prostate cancer but taking more than is required is not beneficial or could even be harmful.
Another randomised study from the USA involved 93 volunteers with early prostate cancer, who had opted not to undergo conventional therapies. They were randomly assigned to intensive lifestyle counselling, or not. PSA levels decreased by 4% at 12-months in the intervention group, but increased by 6% in the control group; this was statistically significant. As a secondary end point, serum taken from patients from the intervention group and introduced to prostate cell lines in the laboratory were 8 times more likely to inhibit their growth than those not given the serum. Furthermore, changes in PSA and cell line growth strongly correlated with the degree of lifestyle change.
A second prospective study, evaluated 48 men with PSA relapse post radiotherapy or prostatectomy. There was a significant prolongation of PSA doubling time (PSAdt) from a mean of 15-months at baseline to 54-months post consumption of approximately 200ml pomegranate juice a day. As a secondary end point, the patients⡳eline oxidative state was significantly lower after pomegranate consumption compared to baseline.
Eating more fruit, fibre, berries, pomegranates, exercise and stop smoking - a section of this website has been dedicated to lifestyle after cancer