Anxiety and active surveillance — more than most men can cope with?
An article just published in the online version of Cancer suggests that:
- While many men are appropriate candidates for active surveillance (AS), in 2006 only about 10 percent of those eligible actually chose it (up from about 6 percent in 2000), and furthermore
- Of those that do initially choose AS, up to 50 percent will convert to active treatment later (either because of indicators of progression or for other reasons)
It would appear that anxiety is common in these men and may exceed grade or biopsy progression as a critical prompt for many men to switch to active treatment (or perhaps to avoid AS in the first place).
The natural history of prostate cancer is heterogeneous and is also still far from being well understood. Since the availability of PSA testing, the majority of newly diagnosed patients in the developed world are now initially identified with low-volume, nonpalpable, early-stage tumors. Autopsy and early observational studies have shown that about 1 in 3 men aged > 50 years has histologic evidence of prostate cancer, with a significant portion of tumors being small and possibly clinically insignificant. Several centers have recentkly been gaining considerable experience with active surveillance apllied in conjunction (as necessary) with delayed, selective, and curative therapy.
Dr. Dall’Era and colleagues have conducted a comprehensive overview of the AS literature to evaluate the rationale behind AS for prostate cancer and to describe the early experiences from surveillance protocols. The rationale for AS is that many men are diagnosed with CaP with a 12-year lead time, and almost eight times as many men are diagnosed with prostate cancer each year as will die of it. Data suggests that AS with delayed intervention if necessary does not put the properly selected patient at risk for disease progression.
It appears that a limited number of men on AS have actually required treatment, with the majority of such men having good outcomes after delayed selective intervention for progressive disease. The best candidates for AS are being increasingly well defined, as are predictors for active treatment. The psychosocial ramifications of surveillance for prostate cancer can be profound and future needs and unmet goals are also addressed in this paper.
The most common criteria used to select patients for AS are a Gleason score ≤ 6, a PSA level of < 10 ng/mL, and a clinical stage pf T1c or T2a. Additional characteristics considered by some include a PSA density < 0.15, a positive result in < 33 percent of biopsy cores, and an extent of cancer-positive tissue in any core of < 50 percent, with stable PSA kinetics prior to diagnosis.
The criteria used to follow patients also vary. Ballentine Carter at Johns Hopkins has described a PSA and DRE every 6 months with an annual prostate biopsy. Others describe checking PSA every 3 months, with a repeat prostate biopsy at 1 year. Using a grade progression to Gleason 4+3 or greater on re-biopsy only stimulated 4 percent of men to be treated due to grade progression. A PSA doubling time of < 3 years is the more common trigger that stimulates treatment intervention. This resulted in 21 percent of men converting to treatment.
Prostate cancer-specific deaths are rare in patients initially managed with AS. However, up to half of all men on AS come off and seek treatment without evidence of progression due to their concerns about disease status.
Filed under: Diagnosis, Management, Treatment
I have seen several references to the anxiety associated with any kind of delayed treatment for prostate cancer and can understand how this arises because of the constant, unrelenting pressure to “do something” not to mention the frequent, incorrect references to the ‘fact’ that this is disease is one the biggest killer of men and it is only by having treatment, the sooner the better that the man can avoid a long and very painful death. The fact is that these pressure so often reflects the anxiety of the people giving the advice rather than the verifiable facts about the disease. As Lu-Yao is quoted as saying: “The deep-rooted fear about cancer may drive the decision-making process, rather than scientific evidence.”
I wonder how many men who choose immediate treatment on the understanding that they will be ‘cured’ are aware of the fact that they will be watching for recurrence for at least 10 years after treatment – and will, if we are to believe the one study I have seen on the subject, suffer the same levels of anxiety as men who choose not to have immediate treatment. see the extract below from Active surveillance for favorable risk prostate cancer: what are the results, and how safe is it? Klotz L. -PMID: 18082582
“The psychological effects of living for many years with untreated cancer are a potential concern. Does the cumulative effect, year after year, of knowing one is living with untreated cancer lead to depression or other adverse effects? The best data on this comes from a companion study to the Holmberg randomized trial of surgery vs. watchful waiting in Sweden. It found absolutely no significant psychological difference between the two groups be after five years. Worry, anxiety, depression, all were equal between the two arms. While surveillance may be stressful for some men, the reality is that most patients with prostate cancer, whether treated or not, are concerned about the risk of progression. Anxiety about PSA recurrence is common among both treated and untreated patients. It is hoped that with education patients will begin to understand the very indolent natural history of most good-risk prostate cancers and, with the realization that the disease is not life-threatening, may avoid much of this anxiety.