ONE MAN TO ANOTHER
Watchful Waiting: Seldom a Good Treatment Option
I’m the Secretary of the URF Board and a patient of Dr. Catalona. He performed my radical prostatectomy in September 1997. I’ve written in QUEST for 5 years. I study and write and counsel and lecture, but I am not a doctor.
Search For Silver Bullets
As a little boy I crowded near my radio to listen to the adventures of one of my superheroes, the Lone Ranger. When he heard of trouble in town, he would work with Tonto to confront the villains and defeat them with strength and using his guns with silver bullets. Everyone now calls a single bold stroke solution to a problem “a silver bullet” solution.
It certainly would be wonderful to have a silver bullet solution to prostate cancer. However, the trouble with searching for silver bullets is that the world is too complex, and the suggested silver bullet usually turns out to be insufficient
The modern approach to solving problems is to try to find a properly connected set of options so arranged that each backs up the other, and the total result is better than each option alone.
My desire is to try to understand how almost everyone with prostate cancer can be returned to a good life – not just the lucky ones – and that’s why I write so often of such comprehensive approaches.
Finding A Starting Point
Finding a starting point for a comprehensive plan for prostate cancer is controversial. I previously wrote to you that my “moment of awakening” occurred after Dr. Catalona persuaded the NCCN (National Comprehensive Cancer Network) to adopt practice guidelines for 2004 that followed his theory of treatment—which had also become the common theory of treatment at these major centers of national excellence. The guidelines were updated again in 2006.
Many men only saw the lowering of the screening threshold to 2.5 ng/ml in the guidelines, but that awareness was far from the whole picture. Lowering the screening threshold reduces the tumor volume, lowers the stage (extent) of the disease, reduces the Gleason Score, extends the time to recurrence if it will occur, and reduces the rate of recurrence.
Best of all, after surgery, use of adjuvant or salvage radiation therapy to avoid recurrence or stop it from continuing becomes much more effective with these earlier tumors.
I realized that surgery, plus radiation if required, provide a strong starting point for a comprehensive plan of treatment. Subsequently, I’ve been writing about how other therapies fit into this baseline plan. This time, I am discussing Watchful Waiting (WW).
I am not an advocate for any kind of watchful waiting, and there is no general agreement that calling it WW is correct. However, I have never seen a book or general article about treating prostate cancer that did not say WW is part of the story. It broadly reflects the passionate views of a group of men who are trying to avoid or delay use of all of the standard therapies, and of a small group of doctors who feel that watchful waiting approaches are more patient-sensitive.
Watchful Waiting—Case Study #1
Dr. Catalona wrote about the so-called Toronto Study, which is the largest WW trial run to date. Researchers found that 60% of the men who seemed to have the mildest types of prostate cancer were not yet treated during a follow-up interval of zero to 10-years later. However, of the remaining 40% of men who had progressing cancer, 58% no longer had an organ- confined tumor. “… of the patients who demonstrated evidence of cancer progression, nearly 2/3 had progressed beyond the prostate at the time of delayed treatment.”
Watchful Waiting—Case Study #2
The Poughkeepsie Man-to-Man Newsletter tells the story of a man who was diagnosed with CaP at age 58. He strongly wanted to reach age 65 and retirement without having to endure any of the risks of conventional therapies. He reported that his Gleason Score was either 7=4+3, or 8, depending on which pathology lab did the reading. He chose to use so-called “Triple Hormonal Therapy”, which includes drugs like Lupron, Casodex, and in his case, Avodart. After 8 years his PSA is holding at 0.5ng/ml (over the last 9 months). He feels that he has made a reasonable and effective decision and that, if he needs them, surgery and/or radiation will be available to solve later problems.
Watchful Waiting—Case Study #3
Another patient support group tells of a man who used his version of WW over a 12-year period. In 1994 his Urologist reported that he had a PSA of 7.3 ng/ml, and a Gleason Score of 6. The doctor recommended surgery, but the patient refused. He took a “ploidy” reading of the tumor (chromosome pattern) and was told that he had the diploid or slower growing form.
He took Flutamide for about two months. He stopped for two months, and then started Lupron and Flutamide for 12 months. He has been on intermittent combined hormonal therapy ever since. In 2002 he started testosterone replacement therapy, to which the doctor added “antiangiogenic cocktail” in August 2003 after his PSA rose to 17ng/ml. His PSA dropped to 0.47 ng/ml. The doctor agreed to again try testosterone replacement therapy, and this time his PSA rose to 20 ng/ml. He then tried low-dose chemotherapy with combined hormonal therapy. His PSA went down but he reports that he lost weight and energy.
He feels that he has made a reasonable and effective set of decisions, and that he’s happy with the outcome.
Why I’m not a supporter of any type of watchful waiting (WW)
Someone telling me that some treatment approach worked for him always influences me. I hope for everyone’s good health and if some therapy worked for a patient then he surely was a winner.
In addition, short periods of WW are inevitable as patients wait for treatment to begin. Nevertheless, I think that medical care is not a collection of quirky possibilities. The goal is to bring almost all patients back to a state of good health.
Most of the WW cases are unusual and it is difficult to evaluate the personal judgment by some doctor(s). The following are a few of the problems that doctors and patients face:
1. WW is primarily a method for delaying the date of treatment. If treatment is later required, the patient is older, more likely to have other diseases, and often less able to use the full range of therapies.
2. Almost all WW ideas focus on patients with a Gleason score (GS) of 6 or less. However the scoring has a problem. Dr. Gleason pointed out many years ago that GS=6 seems to act in two ways. Sometimes it’s like GS=3+2, and sometimes it’s like GS=3+4. Notice that in case study #3, the patient tries to separate the cases using a ploidy test. However many noted pathologists have said that such results are unreliable.
3. The basis for all WW approaches is the flawed assumption that the optimum time of treatment is reliably knowable and your doctor knows the answer for you. It’s not true.
An insightful paper by D’Amico and Catalona (2004) compared PSA velocity (PSAV) to disease recurrence, death from prostate cancer and death from any cause. The startling result was that 24 of 262 men with annual PSAV of more than 2 ng/ml/year, but only 3 of 833 patients with lower PSAV died from prostate cancer. If the cancer begins to rapidly grow then it’s hard to stop, and no one can monitor the cells well enough to guide patients to avoid serious trouble.
4. A man has to be a very rugged soul to endure each variation of PSA and not become overstressed. In fact, less than 10% of men choose WW as their approach.
My Bottom Line
Watchful waiting is still mostly promise with high risk for the patient. There are exceptional cases where it may make sense for some man, but as of today, it’s not a good candidate to improve a comprehensive approach to treatment.
Feedback is encouraged. Contact Dr. Catalona at www.drcatalona.com (see “contact us”), or send me an e-mail at firstname.lastname@example.org. All 14 prior articles are available on the above Website (Click on Quest Articles and then under my picture).
Click here to read the next article, Drug Therapies for Advanced Disease: A Positive View, in the One Man to Another series from Jules Reichel