Kevin Lomangino is the managing editor of HealthNewsReview.org. He tweets as @klomangino.
The New York Times today had a front-page story noting that growing numbers of men diagnosed with prostate cancer are opting for active surveillance of their cancer rather than more aggressive surgery or radiation.
Just 10 percent to 15 percent of early-stage prostate cancer patients were being treated by active surveillance several years ago. Now, national data from three independent sources consistently finds that 40 percent to 50 percent of them are making that choice.
It’s good to see such prominent attention being given to overdiagnosis and overtreatment of prostate cancer — an issue we’ve been writing about on the blog for years. And the story is well worth your time, as it does a nice job of summarizing the major benefits, potential harms, and uncertainties that surround this approach.
But a patient advocate — Joshua Schneck — wrote to us with some concerns about comments from a urologist quoted in the story. The urologist, Dr. Alan J. Wein, said there were no long-term outcomes data to support the benefits of active surveillance. Here’s what Wein told the Times:
We need follow-up of at least 10 to 15 years to be sure we are not hurting these people. The problem is we’ve been in the active surveillance business only since about 2000, and everyone started off very, very slowly. No one really has a number of patients who have gone for years and years.
Schneck, who’s written previously for HealthNewsReview.org about prostate cancer screening, said such data do indeed exist and that the story should’ve mentioned them. Citing the 10-year findings of the Prostate Cancer Intervention versus Observation Trial (PIVOT), which found that surgery did not significantly reduce all-cause or prostate cancer mortality in a group that met recognized criteria for consideration of active surveillance, Schneck said the story inappropriately “leaves the impression, reflected in a reader comment, that there is no research supporting active surveillance. Not true.”
To sort out the issue, I turned to Richard Hoffman, MD, a HealthNewsReview.org contributor who’s written extensively on prostate cancer screening and treatment. He told me that the Times quote is technically correct, in that the longest study of active surveillance comes from a Toronto cohort that’s only been followed a median of 6.8 years. He noted that the The ProtecT trial, a randomized comparison of surgery vs. radiation vs. active surveillance is expected to publish findings this year—patients were enrolled from 2001 to 2009.
But Hoffman said that the PIVOT study data cited by Schneck are also relevant to decision-making about active surveillance and would have provided context to the Times’ coverage. PIVOT compared prostatectomy to watchful waiting, a form of prostate cancer monitoring that’s less intense than active surveillance. (Here’s a quick overview of the differences.) And the results generally support the notion that aggressive treatment may not offer benefits over monitoring for low-risk patients. Hoffman said:
Yes, if we look at PIVOT, overall there was no treatment benefit compared to watchful waiting. The post-hoc analyses suggested possible benefit for high-risk patients. However, there was clearly no benefit for the low-risk patients–who would meet criteria for active surveillance (which would represent a more aggressive approach than watchful waiting). Because PIVOT enrolled a large proportion of patients with screen-detected cancers the results are relevant to decision making about active surveillance.
Aggressive prostate cancer tumors can spread before they are detected, whereas slow-growing cancers are easier to find but may never pose a problem to the patient. Thus, Hoffman says, prostate cancer poses a dilemma summed up perfectly by a quote from the urologist Willet Whitmore.
“The quandary in prostate cancer: Is cure necessary in those for whom it is possible, and is cure possible in those for whom it is necessary?”
Hoffman added that he was troubled by an anecdote in the Times story about Mike Stetsal, a 55-year-old commodities trader who “was told last summer that he had prostate cancer after his doctor ordered a blood test for flulike symptoms that happened to include a PSA test.”
The Times reports that a slightly elevated PSA level led Stetsal to receive more tests, including a biopsy that showed cancer — but which ended up being a false-positive result.
While PSA screening guidelines from major medical organizations may differ on some specifics, they all recommend that PSA testing be done only after a discussion with the patient about the potential risks and benefits of the test. The test should never be given without the patient’s knowledge and approval.
And so despite the fact that more men are opting for less intensive treatment of low-risk cancers, at least some providers are still hewing to an overly aggressive screening paradigm.
“In this day and age it’s very disconcerting to learn that providers are ordering blood test panels to evaluate a patient with the flu that also includes a PSA,” Hoffman said.
“So much for informed decision making.”