In prostate debate, doctors and patients often at odds
Treatment is not always necessary and therapies can have serious side effects, but patients demand action
From the May 1997 ACP Observer, copyright © 1997 by the American College of Physicians.
By Jennifer Fisher Wilson
Despite controversial recommendations against routine screening for prostate cancer and treatments that have potentially serious side effects, many patients still insist on being screened and treated for the disease.
Speakers at "Controversies in Prostate Cancer Management" said they personally believe in watchful waiting for many elderly patients with early stage prostate cancer. They also pointed to evidence such as the March 15, 1997 issue of Annals of Internal Medicine, which suggests that internists should not routinely screen patients for prostate cancer. Patients and their families, however, often feel differently.
While more than 300,000 men will be diagnosed this year with prostate cancer, only 10% to 15% will die from their disease, said Peter C. Albertson, MD, a urologist at the University of Connecticut Health Center. But pressure from patients and their families leads to treatment in all but a few cases when prostate cancer is detected.
Screening has become routine in most men over the age of 50, even though the treatment may not be necessary. "The more we screen, the more we find prostate cancer," said Dr. Albertson. Increased findings lead to increased treatment.
"The assumption is if you find cancer, you'll do something for it," said radiation oncologist Anthony Zietman, MD. "How do you tell a 70-ish man you're going to do nothing? In the U.S., people expect that treatment will help."
Is doing nothing best?
Dr. Zietman noted that treatment remains controversial, however, because it may lead to "devastating" complications in some people such as incontinence and impotence. While most physicians agree that doing nothing is the best strategy in patients who have less than 10 years to live, many disagree over how aggressively to treat men in their 50s and 60s with the disease. In many of these cases, tumors grow slowly and do not spread, making treatment unnecessary.
In addition, both patients who are surgically treated and patients who receive radiation therapy often report a lower quality of life following treatment, Dr. Zietman said. Incontinence, for example, strikes up to 10% of treated patients and impotence at least 50%. Even so, most patients feel compelled to opt for treatment.
Both radical prostatectomy surgery and radiation therapy have similar efficacy rates and similar side effects, although side effects of radiation may take longer to manifest themselves. To help avoid the recurrence of prostate cancer, younger patients are more likely to be treated with surgery; older patients, on the other hand, may tolerate radiation better than surgery.
Dr. Zietman noted that even the newest forms of treatment have potential downsides. One of the most-talked about new treatments, interstitial (seed) radiation therapy, yields good results in expert hands, but the quality depends on how accurately the seeds are placed in the prostate gland. "It's very hard to see how well you're spacing the seeds," he said. If the seeds aren't placed in such way that all the cancer cells are killed, the cancer may remain in the body.
Dr. Zietman added that not all patients are suitable candidates for seed implants. In men with a large prostate gland, the radiation may make actually enlarge the prostate and cause an obstruction. To prevent such obstructions, patients often receive five weeks of external radiation or three months of hormone therapy to shrink the prostate before interstitial radiation treatment is performed.
One new surgical technique is cryosurgery, in which urologists use nitrogen to freeze the malignant prostate. Dr. Albertson noted that too much freezing, however, may damage the rectum, requiring the patient to have a colostomy. Another risk of freezing is damage to the urethra, which can also lead to serious side effects.
The physicians also discussed the use of hormone manipulation in treating prostate cancer. Androgen deprivation has been used to decrease the symptoms associated with prostate cancer, including the pain that patients often suffer, but data are incomplete. "We don't know if androgen therapy increases survival," said Dr. Albertson. "Some people believe early androgen therapy equals increased longevity." He noted, however, that the treatment can lead to a decrease in PSA levels, which leads some patients to cease therapy.
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