Prostate Cancer Treatment Options
The choice of treatment for prostate canceractive surveillance (also known as expectant management), surgery, radiation therapy, or hormone therapydepends on the clinical stage of the cancer and the age and general health of the individual. In healthy men with a life expectancy of more than 10 to 15 years, about 80 percent of prostate cancers detected by PSA testing are believed to have the potential to progress and thus warrant treatment.
Nevertheless, with increased use of PSA screening, some men will be diagnosed with small prostate cancers (which cannot be felt during a digital rectal exam but are confirmed by biopsy) that pose no immediate threat and may never need treatment. Two recent studies suggest that 30 to 50 percent of cancersdepending on patient agedetected by PSA screening would never have become apparent otherwise.
Potential complications of the various prostate cancer treatments must be taken into consideration when deciding on a treatment plan. For example, if a man opts for surgery or radiation therapy, he risks the possibility of bowel, urinary, or sexual problems. This is perhaps of even greater importance for older men with "favorable risk" prostate cancer, in whom the likelihood of complications from treatment outweigh the risk of dying of prostate cancer.
This concern, coupled with the finding that many prostate cancers never need treatment, prompted the National Comprehensive Cancer Network (NCCN) to issue prostate cancer treatment guidelines recommending active surveillance (no treatment initially but continued careful monitoring) for men with very-low-risk prostate cancer who have a life expectancy of less than 20 years and for men at low risk when life expectancy is less than 10 years.
Doctors use several methods to help predict the seriousness of the cancer, which is factored into the treatment decision. For example, a Gleason score of 5 or 6 indicates a greater probability that the cancer is insignificantand unlikely to grow rapidly and spread. Higher Gleason scores suggest a greater likelihood of a significant, life-threatening cancer. Men with high-grade disease (defined as a Gleason score of 7 to 10) are considered poor candidates for active surveillance because of the presumed aggressiveness of their cancer.
In addition to the Gleason score, the PSA level and the stage of the disease are used to stratify men into risk categories that help physicians determine the optimal management strategy. A man's age is also an important consideration when choosing between active surveillance and a more aggressive treatment option.
Because prostate cancer generally progresses slowly, active surveillance is less risky in older men with small tumors. In fact, data show that men in their 70s and 80s who are diagnosed with very-low- to intermediate-risk prostate cancer are more likely to die of a cause other than their prostate cancer over a 10-year periodeven without treatment. Men in their 50s and early 60s, in contrast, are more likely to live long enough for their prostate cancer to become life threatening. Prostate cancer experts at Johns Hopkins believe that the best candidates for active surveillance are over age 65 and have very low-risk prostate cancers.