By Stephen Spotswood
ATLANTA — For patients diagnosed with a malignancy, the natural response is to ask the physician to do everything possible to treat the cancer.
The challenge for VA clinicians and others, especially with older patients who have prostate cancer, is to help them understand that the best option might instead be to do as little as possible.
While some physicians refer to this option as “watchful waiting” or “active surveillance,” both fall under the heading of “expectant management” — a catch-all term for what is essentially keeping a close eye on a slow-growing or non-growing tumor.
Determining whether expectant management is the right course of action is not only dependent on metrics of the tumor but also on the lifestyle and goals of the patient. That invariably leads to an uncomfortable conversation and a difficult decision.
“For a lot of low-risk cancer, treating a patient with surgery or treating them with radiation won’t allow them to live longer,” explained Chris Filson, MD, MS, a urologist at the Atlanta VAMC who has studied the use of expectant management in veterans. “There’s also the understanding that these treatments have a lot of side effects, and we want to avoid them.”
Prostate cancer is the most common cancer among men in the United States, and more than 12,000 new diagnoses are made each year at the VA. The cancer is a special focus there, because exposure to herbicides is among the several additional risk factors for prostate cancer, In fact, prostate cancer is a presumed service-connected condition for veterans who served in Southeast Asia during the Vietnam War.
Since the introduction of Prostate-Specific Antigen (PSA) as a screening test during the 1980s, more than 80% of the prostate cancers diagnosed at VAMCs are localized to the prostate gland, with only about 5% percent of patients having metastatic cancer at the time of diagnosis.
In addition, most prostate cancer patients are diagnosed at an older age, averaging 66. Because many of their tumors are found to be indolent, meaning they cause little to no pain and are slow-growing or non-growing, patients often spend the last years of their life with prostate cancer but never showing any symptoms.
Three factors determine how much risk a tumor presents to a patient. The first is prostate-specific antigen levels (PSA) — the lower the better. Then there’s the physical exam: If a physician feels a nodule or lump, that’s a sign of a larger tumor. Lastly, pathologists look at a sample of the tumor and assign it a number on the Gleason score. The higher the score, the more likely it is to spread quickly.
Patients whose tumors are found to be low risk often are offered expectant management as a treatment option. “There are a number of new things coming down the pipeline that are already available in some settings that can help make that decision,” Filson said. One of these is MRI imaging, which can help determine if a cancer is more aggressive. Another is genomic testing — examining the genes in the biopsy to determine risk.
“It can push the pendulum a little bit toward higher risk or lower risk,” Filson explained. “But it’s yet to be seen whether it’s helpful [in a clinical setting] in or out of VA. It’s also not covered by many insurers, VA or otherwise.”
A critical factor in making the decision is patient preference, Filson added.
“We explain the risks and benefits, and we look at the patients’ desires and needs,” he told U.S. Medicine. “We know now that it’s critical to consider a patient’s own values and wishes, as well as understanding the aggressiveness of the cancer.”
That can be a difficult conversation to have. It involves educating, and in some cases re-educating, the patient on just what it means to be diagnosed with cancer.
“In general, when people hear the ‘C word’ — undoubtedly they have anxiety surrounding that disease,” Filson recounted. “A patient’s desire to be active in treating it has a lot to do with their own experience. They might have had a family member who had cancer or had a friend with prostate cancer who treated it and had side effects or had some people close to them die of prostate cancer.”
It comes down to explaining to patients how much the course of prostate can vary, although it often progresses over a period of years, if not decades. Once the patient understands the disease, the conversation turns to the specifics of the patient’s life.
“A crucial component is an understanding of life expectancy,” Filson said. “Aggressive treatment for patients who are older or sicker tends to have less benefit. Sometimes that’s a difficult conversation to have with a patient who’s 75 or 80 years old who might only have five or 10 years.”
That discussion is complicated by any of the patients’ comorbidities, which tend to increase with age. Because prostate cancer is much more likely to be diagnosed at an older age, patients are more likely to have heart disease, diabetes or any number of complication conditions. All of these can have a significant impact on quality and quantity of life.
“We don’t do a great job of determining patient life expectancy,” Filson explained. That’s especially true once multiple diseases become part of the equation.
“Every patient is unique and different,” he said. “It’s hard to take whatever averages over all people and then to make that transition from averages to the gentleman in front of you.”
As they work with the patient to determine what to do next, physicians are aware of numerous studies released over the past few years indicating that aggressive treatment to cure patients of low-risk tumors has created side effects more harmful and life-disrupting than the cancer itself.
Because some studies have laid some of the blame at improvements in diagnostics that have resulted in more prostate cancer being detected earlier, a backlash has risen up against detection techniques such as prostate screening.
Filson said he doesn’t buy into that. Eschewing detection techniques is not the answer to overtreatment, he suggested, but what’s needed is a better understanding of who might benefit from expectant management.
“[Surveillance as a treatment option] is relatively understudied in VA,” he said. “Though there is a lot of focus on certain aspects of understanding whether or not veterans benefit from aggressive treatment.”
The largest and highest-profile study is the Prostate Cancer Intervention Versus Observational Trial (PIVOT), which VA ran from 1994 to 2010. The study found that radical prostatectomy can have little to no benefit in patients with low-risk tumors and that some patients could benefit from observation.
The results of the study have filtered into the conversation around prostate cancer treatment during the past five years, but it’s unclear whether physicians are recognizing the benefits of expectant management and changing their practice accordingly.
Currently VA does not have explicit guidelines on when to employ surveillance over active treatment, Filson said. “My research interest, moving forward, is to look at what the more contemporary patterns of [surveillance’s] use are in VA.”
His first goal is to understand its use at the local level in VISN 7— the Southeast Network of which the Atlanta VAMC is a part. “I want to get some efforts going to collaborate with other centers in VA in improving efforts and in finding patients who could benefit from expectant management. This is a field of prostate cancer care that I’m deeply invested in and could have profound implications. But the first step is finding who could benefit from it first.”