Treating prostate cancer: No rush to judgment

At your annual check-up, your doctor discusses the pros and cons of a PSA test. You decide to go ahead, and a week later you get a call with the unwelcome news that the result is high. The next step is a repeat test, with another week of waiting. High again, so you're referred to a urologist. It takes three weeks to get the appointment, another week to get your ultrasound-guided prostate biopsy, then a really long week of waiting. Now the verdict: You have prostate cancer. Fortunately, though, it looks like early disease that's very likely curable.

By now, nearly two months have elapsed since your first PSA test. Since your PSA was just 6 nanograms per milliliter, your risk of widespread disease is extremely low, and so you don't need to spend time lining up scans and waiting for more results. You're eager to get on with treatment, but your primary care doctor tells you it's not so simple. You have a choice of treatment, since surgery, radiation, and even deferred therapy ("active surveillance") are all reasonable. Your doctor sets up appointments with the urologist, a radiation oncologist, and a medical oncologist so you can get a full range of opinions. It takes another month to make the rounds, and then you spend a long weekend at a country inn to think things over with your wife.

After all this, you decide to have a radical prostatectomy. But the urologist is a busy man. You're glad that he is experienced and that he does a lot of these operations. But is it safe to wait? Will additional delay reduce your chance of cure?

It's an important question, and two studies can help answer it.

Questions and answers

The smaller and earlier study evaluated 151 men with newly diagnosed prostate cancer who elected to have surgery. The researchers divided the men into five groups based on the amount of time that had elapsed between their diagnostic biopsies and their operations. The shortest interval was just 15 days, the longest was 520 days, and the average was 94 days. The men in the groups did not differ significantly in age or in the stage of their tumors.

The men were tracked for an average of nearly eight years postoperatively. As a group, they did very well, but 32 of the patients developed detectable amounts of PSA in their blood, providing biochemical evidence of recurrent cancer. There was no correlation between the interval between biopsy and surgery and the risk of recurrence. The risk was 18% in men who had their operations within 60 days of diagnosis and 25% in men who waited more than six months for treatment; the results were statistically indistinguishable.

The larger study evaluated 3,149 men who had radical prostatectomies between 1987 and 2002. The much larger sample size is an advantage of this newer study, but the duration between diagnosis and surgery averaged just 2.3 months, and it was greater than six months in just 120 patients. The researchers divided the patients into two groups, 2,258 men who waited less than three months, and 891 who waited longer.

The men were tracked for an average of more than five years. As in the previous investigation, the return of detectable blood PSA was used as evidence of recurrent cancer. Also as in the previous study, the time lag between the diagnosis of cancer and surgery did not predict the risk of recurrent disease.

It's reassuring news, but does it apply to patients with high-risk disease? Because the newer study was so large, the scientists were able to identify 1,201 men who had a high likelihood of having aggressive disease. Even among these patients, there was no link between the surgical delay and the risk of recurrence. And in a subsequent report, the same scientists reported that their results held up even in men who had been followed for 10 years after surgery.

Why wait?

Once a man decides what to do about prostate cancer, there is no reason to wait, but the reassuring research says that men can take the time they need to make their decisions. That means reading about prostate cancer, consulting with experts in the various treatment modalities, talking with other patients, and including family in every step of the process.

It's a difficult decision to make, and it shouldn't be rushed. That's not true of all cancers. For example, two 2006 studies of patients with bladder cancer found that delaying surgery for more than 12 weeks was associated with a worse long-term outlook.

Prostate cancer is different because it's a slow-growing tumor. Even aggressive prostate cancer cells take longer to divide and multiply than cells from most other malignancies. It's why older men with small, low-grade prostate cancers may reasonably choose active surveillance, deferring any form of treatment unless their tumors enlarge or symptoms develop. And it's why most men with the disease respond favorably to all forms of treatment.

In our fast-paced world, many decisions are made in a rush. When a man faces important choices about prostate cancer, it's good to slow down and consider all the options. And now we know that patients can stop the clock without jeopardizing their health.