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:
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.
Disadvantages
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
There is a great deal of evidence that lifestyle can significantly
affect the rate of progression of prostate cancer. The largest UK trial
conducted by Professor Robert Thomas published in 2008 showed that over a third
of men who changed their lifestyle had a a slowing of their PSA progression
(doubling time). These patients also a low dose of salicylate
(aspirin like drug).
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’ baseline 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