“Quality of Life” Trumps Plain Survival

There is a growing consensus among physicians and patients that survival in prostate cancer with quality of life beats plain survival. Prostate cancer comes in basically two patterns of behavior (low-risk and high-risk), and the vast majority diagnosed by screening today (85%) is a low-risk, indolent cancer which takes many years to develop. The problem is that the words “cancer” and “indolent” don’t fit well with most people’s conceptions of cancer as a disease, and this falls into the patterned behavior of urologists who are trained to take “cancers” out. Active surveillance of low-risk prostate cancer has been shown by various studies to be clinically acceptable and maintain quality of life.

There is little probability that a cancer that can be cured will not be cured if active surveillance is carried out. In the words of the late oncologic urologist Dr. Whitmore: “If the prostate cancer is curable is treatment necessary, and if treatment is necessary is cure possible?” The undercurrent of his allusion implies that we are dealing with two different diseases, and we actually don’t know if one morphs into the other. Many men are found to have died with prostate cancer from other causes rather than of it. The concept that low-risk prostate cancer does not kill people is not being taught to patients.

Of course once active surveillance is chosen close follow-up is necessary to avoid the charge, in our litigious environment, that a window of opportunity was missed. The decision of when to turn from surveillance to treatment will always be a point of contention, but this can be reached jointly by patient and physician as they assess the objective findings being followed.

As patients become more educated, they are less likely to go through “knee-jerk” treatment after diagnosis. Over-diagnosis and over-treatment are likely to increase with the American Urological Association recommendation to begin screening at age 40. Autopsy series reveal that 30% of men in their 30′s have histologic evidence of prostate cancer. Treating young people with low risk disease condemns them to a decreased quality of life, when the latency period of their disease could be quite prolonged. There is enough evidence to suggest that active surveillance is a sound initial strategy in low-risk prostate cancer.

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