A sea change is occurring among men with low-risk prostate cancer: Increasing numbers are avoiding immediate surgery or radiation and are opting instead for close monitoring of the disease to see whether it worsens. The shift is sharply reducing unnecessary treatment that can cause serious side effects including incontinence and sexual problems, experts say, without increasing the risk of death.
The latest evidence of the long-term trend came in a large study published Tuesday that involved more than 125,000 veterans diagnosed with nonaggressive prostate cancer between 2005 and 2015. Researchers found that in 2005, only 27 percent of men under 65 chose to forego immediate therapy and instead signed up for “watchful waiting” or “active surveillance” to keep track of the tumor. By 2015, the situation had flipped - 72 percent rejected immediate surgery or radiation in favor of such monitoring. The data for men older than 65 was similar.
The study, which appeared in JAMA, was conducted by researchers at NYU Langone Health and Department of Veterans Affairs NY Harbor Healthcare System.
“I think it’s hugely important,” said Otis Brawley, chief medical officer of the American Cancer Society, who was not involved in the study. “Remember that until 2010, a man diagnosed with prostate cancer was told to get your prostate out, next week at the latest.”
Brawley, who has long warned about the dangers of overtreatment of prostate and breast cancer, said the study shows that efforts are beginning to pay off to convince patients that some low-risk malignancies don’t immediately require aggressive responses. And he said the study is a leading indicator of where the rest of the country is going; about half of non-VA patients with the same type of malignancies are now rejecting immediate treatment and the number is growing quickly.
“The VA is the tip of the spear,” he said. “Five years from now, the whole country will be at 70 percent.”
Stacy Loeb, who led the study and is a urologist at NYU and the Manhattan Veterans Affairs Medical Center, said the change represents “a historic reversal, at least at the VA, in the decades-long overtreatment of men with prostate cancers least likely to cause harm, and brings their care more in line with the latest best practice guidelines.” The guidelines include recommendations, issued in recent years by the American Urological Association and the American Society of Clinical Oncology.
Over the years, most of the increase in the surveillance-only arm, she said, occurred in a category called “active surveillance,” in which men are subjected to more rigorous monitoring and testing than those in “watchful waiting.” While 4 percent of men chose active surveillance in 2005, 39 percent selected it in 2015, the study showed.
The researchers said that there were likely many reasons why VA was adhering to national guidelines at a higher rate than other parts of the health care system - including the lack of financial incentives for the salaried physicians to recommend more aggressive treatment.
Jonathan Simons, president of the Prostate Cancer Foundation, which helped fund the study, said that while the VA medical system has some problems, when it comes to the “No. 1 cancer of veterans, prostate cancer, the outcomes are better in VA hospitals than in the rest of American medicine.”
Clark Howard, an Atlanta resident who writes and does a radio show on consumer issues, was one of the earliest patients to opt for active surveillance rather than aggressive treatment. He was diagnosed with low-risk prostate cancer at age 53 in 2009, and his doctors pressed him to immediately schedule an operation. He refused.
“My wife thought I was crazy and burst into tears,” he said. “I have never seen her scream and weep like that, she was so mad.”
As part of the monitoring of his cancer, Howard gets PSA (prostate-antigen specific) tests twice a year and biopsies every other year. He also has had two MRI-based tests. His cancer hasn’t worsened; if it does, he says, he’ll get treatment then. “So many people are conditioned that cancer must be treated aggressively and immediately and if you don’t, you are going to die,” he said.