Low Risk Prostate Cancer Often Is Over Treated

BETHESDA, MD — Many men are receiving curative therapy for prostate cancer who would be better served by more passive, observational treatment, according to a panel of experts convened by the NIH.

After examining the available research — much of which came from an unpublished study of VA patients — the panel suggested that the paradigm for prostate cancer needs to change, especially for patients whose cancers are shown to be low or intermediate risk.

Patricia Ganz, MD, panel chairperson and proffesor of medicine at the University of California

While many men will benefit from immediate surgery or radiation, many also would benefit from delaying treatment and adopting a “watchful waiting” approach, according to panel members.

The panel identified emerging consensus in the medical community on a definition for low-risk prostate cancer: a prostate-specific antigen (PSA) level less than 10 ng/mL and a Gleason score of 6 or less. Using this definition, the panel estimated that more than 100,000 men of the 240,000 diagnosed with prostate cancer in the United States each year would be candidates for active monitoring, rather than immediate treatment.

“The natural history of prostate cancer has changed over the last 30 years,” explained Patricia Ganz, MD, panel chairperson and professor of medicine at the University of California, Los Angeles, at a press briefing following the conference. “With screening, we now have many men being diagnosed with low-grade and low-stage prostate cancer.”

This early detection means that the cancers being discovered are not always serious enough to warrant surgery or radiation, Ganz said. However, the culture in the field still heavily favors curative treatment.

“When men are given a diagnosis of cancer, it is very difficult to decline the standard therapy for this disease, which would be surgery or radiation therapy,” Ganz said. “But data from studies suggests that a more conservative monitoring strategy may be equally effective for men in terms of positive outcomes.”

Asked if men with prostate cancer are being “oversold” on the benefits of surgery, Ganz admitted that there might be bias — unconscious or otherwise — on the part of specialists to push for the curative approach.

“If a patient presents to a urologist, a more conservative approach may be offered,” Ganz said. “But the way in which it’s presented, the order in which it’s presented or hidden communication that the physician makes to the patient indicates that the observational strategy is not preferred.”

A diagnosis of cancer sets off an emotional response in patients, causing them to seek the most active treatment regimen, which already makes them lean in the direction of radiation or surgery, Ganz added. “There are many, many cancers that we overtreat.”

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