While controversial to some, many local doctors are eyeing this form of treatment, or more accurately, this lack of treatment. | Also: Get the latest at L.A. prostate cancer conference
Rather than going through traditional therapies of surgery or radiation, men with low-risk prostate cancer can opt for this wait-and-see protocol where doctors keep an eye on the disease until it begins to progress, if ever, before moving forward with treatment.
It's a method that doctors at Cedars-Sinai Medical Center have become fond of for the right patients.
"No person wants to be diagnosed with cancer and the natural reaction is well, we'll get rid of it. But at what cost? A man who undergoes surgery for prostate cancer is at risk of being unable to have an erection; being in a position where urine leaks when he laughs, when he exercises, when he lifts something heavy, with any kind of abdominal pressure," says Dr. Edwin Posadas, a prostate cancer specialist at Cedars-Sinai.
"Now, if you're going to save his life from doing that, that's great," he says. "But you want to identify those other patients and say, `You know what? You should not go to surgery or get radiation therapy at this point in time."'
Prostate cancer is the most common cancer in American men, with one in six affected by the disease, and while it's the second-leading cause of cancer
deaths in men, it's actually a minority of patients who are at risk of dying from the disease, explains Posadas.Adding to the debate are recent studies, including one published in the New England Journal of Medicine indicating that among men with localized prostate cancer, surgery to remove the prostate did not significantly affect life expectancy.
It could be more than 10 years for certain low-grade prostate cancers to begin progressing. And generally the disease affects men in later stages of life, with the risk increasing at age 60.
"If a prostate cancer is slow-moving, there's a lot more men who will actually die with prostate cancer than of prostate cancer," Posadas says.
To determine the type of prostate cancer they have, men will be given a Gleason score between 2 and 10, though most often the number is 6 or higher, and a prostate-specific antigen (PSA) level.
The Gleason grading system is used to judge how aggressive and fast the cancer might spread based on the cancer's microscopic appearance. Higher scores mean it's more likely to have spread past the prostate. A Gleason 6 is considered low-grade, 7 is intermediate and 8 through 10 is high-grade.
Doctors can decide to offer active surveillance on a case-by-case basis, but that's where controversy arises.
While USC Institute of Urology also practices active surveillance on the appropriate patients, the executive director of the clinic, Dr. Inderbir Gill, says knowing who those patients are is not always easy.
"The con side of active surveillance is we don't know in a definitive way whether the patients have truly low-risk disease," says Gill.
"In other words, low risk is defined as PSA less than 10 and Gleason 6, or less than 7. In certain high-volume Gleason 6 scenarios, there is about a 25 to 30 percent chance that actually the patient may have more disease in the prostate than identified by the needle biopsy."
Because of this, Gill recommends patients who are given a low-risk diagnosis get a second biopsy to help confirm the primary diagnosis before going on an active surveillance protocol.
But Cedars-Sinai is taking it a step further.
The entire medical group's Cancer Center has united in an effort to make the hospital the West Coast leader in active surveillance by forming the National Proactive Surveillance Network.
"We're attempting to create this network, this resource for which men with low-grade, low-stage prostate cancers will enter this registry," Posadas says. "We'll follow them clinically but what we'll also do is - understanding the limitations of where we are today - we'll begin collecting tissue, blood and urine to try to find additional information that could be very helpful to a man facing the decision of whether or not he needs surgery or radiation.
"In other words, what we're trying to do is help to generate personalized medicine in prostate cancer and that's really, really where we gotta go at this point in time."
So while doctors have parameters to determine a course of action such as Gleason scores, PSA levels and a clinical state, those don't offer all of the information needed.
For example, when a woman is diagnosed with breast cancer her doctor will give her molecular information about her specific disease, such as her estrogen receptor status and her Human Epidermal Growth Factor Receptor 2 status.
This information is a strong indicator of which therapies she will receive in the future, says Posadas, and that is what is needed for prostate cancer.
"It's a bit embarrassing to admit this, but in prostate cancer we don't have a language or a classification yet that is based on molecular information," Posadas says.
"We kind of still urgently need this in prostate cancer. So the Gleason score, it's kind of like looking at a car from the outside - it looks fast or it looks slow but you can never tell. Sometimes these low-stage things have molecular clues in them that make them behave very differently in the future and until we develop that language and we get those data sets, we're in the dark. And that's hopefully what the NPSN will do."
The idea of active surveillance does not diminish how life-threatening the disease can be for certain men. Posadas agrees it is a major health care issue and men should be aware of it, but they should also be aware of their options and feel empowered to make the decisions that are appropriate for them.
As he says, treatment is about the right patient at the right time.
"It's frightening to me when we think about the number of patients - healthy men terrified of what their future may look like - who go in for a surgical procedure or a radiation therapy that they don't need and their lives can be dramatically changed at the end of the day," Posadas says.
"I've got patients in their 60s and their 70s, people who are happy, active and productive like guys in their 40s, and to take that away from them ... it's criminal when you think about it."
Find out more
For more information on Cedars-Sinai Medical Center's prostate cancer program, call 800-233-2771 or go to www.cedars-sinai.edu.Stephanie Cary 310-540-5511, Ext. 6630 stephanie.cary@dailybreeze.com
Follow Stephanie Cary on Twitter at http://twitter.com/stephiecary
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