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"Watchful Waiting” Not Best Approach to Prostate Cancer
“Watchful Waiting” Not Best Approach to Prostate Cancer After fifteen years of following men in this study, nearly sixty percent of those who received treatment are still alive as opposed to only twenty-seven percent of the men who chose watchful waiting.

Prostate cancer is the most common non-skin cancer in American men with nearly a quarter of a million new cases diagnosed annually. Approximately thirty thousand men die each year from prostate cancer. Through either surgery and/or various radiation techniques, the ultimate goal after diagnosis is to rid the patient of the disease. Patients differ, however, in how they choose to proceed with their individual treatment.

Some men have chosen an approach known as “watchful waiting” in which they are monitored regularly by their physician but do not receive any treatment of their early prostate cancer. While this area has been controversial, a recent study, involving fifty thousand men diagnosed with prostate cancer, has provided some new insights on the “watchful waiting” approach. Approximately thirty-five thousand men in this study chose to receive treatment in the form of radiation or surgery. The remaining patients chose to be observed but to receive no treatment. After fifteen years of following men in this study, nearly sixty percent of those who received treatment are still alive as opposed to only twenty-seven percent of the men who chose watchful waiting. These numbers indicate that early treatment is important and effective. Because it was not a randomized study, it is possible that those deciding not to be treated were already in poor health and that influenced both their decision about treatment as well as the eventual outcome. A more definitive answer about the question of “watchful waiting” as opposed to early intervention will come from two studies: One is being done at the Veterans Administration in the United States and the other in England. In both of these studies, patients are randomly assigned either to receive an intervention of surgery and/or radiation or to receive no treatment except observation. Only through this randomized approach can this issue finally be settled. It is prudent, however, for men in their sixties or younger to continue with treatment albeit these are also men who are most concerned about the side effects of treatment such as sexual dysfunction and bladder problems.

What Tests Are Available?
Most men are aware of the test known as PSA “prostate specific antigen.” The antigen or protein is actually made by normal prostate tissue and is a reaction to the presence of prostate cancer. This is why the PSA can rise with reactions to other situations such as an enlarged prostate gland or an infection. At the other extreme, there are medications that can lower the PSA inappropriately. Two such medications, finasteride (Proscar) and dutasteride (Avodart) are marketed for the treatment of non-cancerous enlargement of the prostate gland known as BPH or benign prostate hypertrophy. Men taking such medications should inform their physician, who may want to reduce the level at which their PSA will be of concern. Recently, more accurate applications of the PSA test are being evaluated. One of these applications is known as the “percent-free PSA” because the more PSA that is measured as being bound to proteins, or not free, the higher the risk of cancer. In other words, most physicians dealing with prostate cancer have decided that having a free PSA of less than twenty-five percent would increase concerns about the possibility of prostate cancer. This cut off point of twenty-five percent is, however, extremely debatable. Another PSA measurement is based on the volume of prostate tissue that is present. Based on this measurement, a man with a small prostate cancer who has a high PSA level should be more concerned than a man with a larger prostate cancer but with the same PSA measurement. Once a man has had his prostate removed or ablated by radiation, he should not have any significant levels of PSA; however, patients are continually monitored for evidence that the cancer is likely to come back. One way of telling if the prostate cancer is likely to be aggressive is based on the PSA velocity. This measurement calculates how rapidly the PSA is increasing over a twelve-month period. Usually a rise of two or more points in the PSA over this twelve-month time span implies a more aggressive malignancy.

Another means of early detection of prostate cancer is the physical examination test known as the digital rectal examination, which is especially important in younger men where elevations in the PSA may not be seen. Prostate cancer may be first detected through the physical examination. Once the physician detects abnormalities on a digital rectal examination, a test known as a trans-rectal ultrasound or TRUS will help localize the area felt on examination and will assist in the ability for a biopsy to determine if cancer is involving the patient’s prostate. In the future, there will be newer testing techniques based on other proteins that are manufactured by the cancer. One in particular is known as the “early prostate cancer antigen” or EPCA, which may revolutionize the early detection of prostate cancer.
Reducing the Risks
While early diagnosis is important, the most effective way to deal with cancer is to reduce the risk of developing it. Heredity plays a role in the development of prostate cancer; but for the time being altering one’s genetics is not an option. It was recently reported in Italy that men who engaged in strenuous physical activity as a part of their occupation had a decreased risk of prostate cancer. This decrease in risk may be related indirectly to the fact that although obesity has not been associated with an increase in the development of prostate cancer, it is quite possibly linked to a more severe and aggressive form of prostate cancer once it develops. Fat tissue in humans is responsible for increased inflammatory proteins in the blood known as cytokines. Before antibiotics were developed, these inflammatory proteins helped maintain a survival advantage by aiding in the recovery from infections, but they also have the ability to stimulate cells in the body to become malignant. These are only theories but the fact remains that there is a body mass relationship to the development of and death from prostate cancer.

Finasteride, a medication mentioned earlier, when used for BPH prevents testosterone from being metabolized to a form that stimulates the prostate gland and as a result, reduces the prostate size. Studies that are more recent have shown that while it may not prevent the development of prostate cancer, it may prevent the development of more aggressive prostate cancers. Another medication known as toremifene (Fareston), which is being studied in women with breast cancer has also demonstrated the ability to reduce the severity of prostate cancer in men. While these newer techniques of trying to prevent prostate cancer are interesting, they can also be expensive and plagued with side effects. One very economical and practical way to intervene would be to change a person’s diet and lifestyle. This change includes not just weight loss but also increasing the amount of lycopene, found in tomatoes and shown to reduce the risk of prostate cancer.

Testosterone Replacement Therapy
Another important issue in the management of prostate cancer is the ability of a man to receive testosterone replacement therapy after being treated for prostate cancer. The problem lies in the fact that one-third of the men with prostate cancer develop hypogonadism, a condition in which testosterone levels become extremely low after the treatment of their localized prostate cancer. Side effects of this condition include a reduction in the libido or sex drive, decreased energy levels, bone loss and anemia. A recent study was conducted in San Antonio, Texas, to evaluate this issue. Testosterone replacement therapy was given to men who had been successfully treated for prostate cancer and who after one year had documented low testosterone levels but no evidence of recurring prostate cancer. It was discovered that despite the testosterone replacement therapy, there was no increased incidence of a rising PSA after the men were given testosterone. In comparison, a group of men was not given testosterone replacement therapy, and they actually showed a nine to ten percent rise in their PSA. While this study should not be interpreted that testosterone is protective against prostate cancer, it does imply that there is no increased risk of having prostate cancer recur if testosterone is given to men who have had definitive treatment of their early prostate cancer. After testosterone replacement, most men report an improvement in their quality of life through decreased hot flashes, improvement in their sexual performance, anemia, and osteoporosis as well as energy levels and muscle mass.

These are just some of the many new issues in the diagnosis and treatment of prostate cancer that are available. Healthy lifestyle choices, regular screening, and early detection and treatment are important for the best outcome while preserving the highest quality of life after the diagnosis of prostate cancer.

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""Watchful Waiting” Not Best Approach to Prostate Cancer"
   authored by:
Dr. Fleming earned his MD degree from the University of Louisville, Kentucky, and completed his fellowship at the University of Kentucky which included an externship at the National Cancer Institute.He became a tenured professor in hematology/oncolog...

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