An article by Linda Beck in the Health Matters section of the Wall Street Journal today weighs in on the pros and cons of “watchful waiting” as a management strategy that is increasingly considered appropriate for many men with low risk, early stage prostate cancer.
The “New” Prostate Cancer InfoLink thinks it would have been helpful if Mrs. Beck had discriminated more carefully between “watchful waiting,” “active surveillance,” and “expectant management” (three commonly use terms with slightly different meanings). However, this is a good article that covers key points in the decision not to have immediate forms of interventional treatment (surgery, radiation, etc.) that may cause as many problems as the diagnosis of prostate cancer itself.
Filed under: Management | Tagged: active surveillance, expectant management, watchful waiting |
THE "NEW" PROSTATE CANCER INFOLINK 
There is another option for prostate cancer patients: focal therapy. This has also been called “the male lumpectomy” — only the part of the prostate where cancer is found is destroyed. Cryotherapy needles are what is being used to treat in this country, and there is a clinical trial going on in the UK that uses HIFU (high frequency ultrasound) to destroy cancerous areas with heat. Extensive biopsies (called 3-D mapping prostate biopsies) can be used to locate the cancer, while some doctors use the latest versions of ultrasound. Side effects such as impotence, incontinence, and the bowel problems are less frequent than with surgery or radiation.
Because a conventional 12-needle biopsy can easily miss or underestimate how aggressive the cancer is, ‘Peter Scardino, chief of urology at Memorial Sloan-Kettering Cancer Center in New York City, says doctors often urge patients to have surgery “not because they think you have a more aggressive cancer, but because they can’t be sure you don’t.” He says he has removed some prostates only to find a much more extensive tumor than expected and thought, “Thank God we operated.”‘ The majority of the men being diagnosed today are considered low risk. Focal treatment gives many patients a chance to hedge their bets with a cure than isn’t going to be worse than the disease. Sloan-Kettering is conducting a clinical trial of focal cryotherapy now.
With respect to Steve’s comment above, I am merely going to add that we have no data whatsoever on the long-term survival benefits of focal therapy. It may well be that the men who are eligible for this type of therapy are commonly those who would do equally well on active surveillance protocols. We just have no idea.
Mike,
Did you get a chance to look at the WSJ’s interactive video about 3D mapping biopsies? What did you think?
I think that the graphics are lovely, and that if you listen to the commentary with care there is (generally) appropriate use of the words “may” and “if”. I also think that the idea of someone playing Battleship with my prostate is an entirely accurate description of this technique.
I have no doubt that this technique can be used to more accurately identify small amounts of cancer (in one or both lobes) of the prostate. However, we still have minimal data regarding whether these small amounts of cancer need to be found at all in many of the men this technique is currently being used on.
Re: “watchful waiting,” “active surveillance,” and “expectant management” (three commonly use terms with slightly different meanings)
Slightly? That’s an understatement. I’ve been having a one-way correspondence with Ms. Beck and a dozen “respected” websites, including well-known institutions, on the definitions of these terms; two-way with the NCI — they’re curious.
Alas … These terms are commonly muddled up and misused. Please click here to see generally accepted descriptions of “watchful waiting” and “active surveillance.” The term “expectant management” is commonly used as a “catch-all” terms to include both of the other terms but with a bias toward active surveillance.
I agree these terms are ‘commonly muddled up and misused’ but the link quoted above does not give accurate descriptions of ‘watchful waiting’ and ‘active surveillance’.
The link defines ‘watchful waiting’ as a protocol in which ‘the doctor will carefully and regularly monitor potential indicators of progression by carrying out PSA tests and DREs on the patient every 6 months or perhaps every year’. This is not confirmed by the literature.
Quote:
Active surveillance aims to individualise the management of early prostate cancer by selecting only those men with significant cancers for curative treatment. Patients are closely monitored using serum PSA levels and repeat prostate biopsies. The choice between curative treatment and continued observation is based on evidence of disease progression during this initial monitoring.
Active surveillance must be distinguished from watchful waiting, which for decades has described a policy of observation with the use of palliative treatment for symptomatic progression. Put another way in order to emphasise the differences between these two contrasting approaches, whereas watchful waiting involves relatively lax observation with late, palliative treatment for those who develop symptoms of progressive disease, active surveillance involves close monitoring with early, radical treatment in those with evidence of significant biochemical or histological progression.
Although active surveillance of one form or another has been widely used on an ad hoc basis, the concept was formally described for the first time in 2001 by Richard Choo from Toronto, in a report of ‘watchful observation with selective delayed intervention for clinical, histologic, or PSA progression’
Parker, C. The Lancet Oncology, Feb. 2004 p.103 (http://tinyurl.com/arc8s)
Choo, R. Int J Radiat Oncol Biol Phys. 2001 Jul 1;50(3):615-20 (http://tinyurl.com/cgujn7)
Dear Axotyl:
Since there are absolutely no established and generally approved protocols or definitions for watchful waiting or for active surveillance, I am not sure what you are trying to suggest. In the early to mid 1990s, watchful waiting did indeed mean “relatively lax observation with late, palliative treatment.” However, that certainly isn’t the case in America today, and probably wasn’t even when Parker wrote his review for Lancet Oncology in 2004. Such “lax observation” would now be considered unethical. And while Choo may well have been the first to use the term “active surveillance” in a published article, the idea behind this was well understood at least 3-4 years before that.
I am not sure why you are relying on definitions that are over 5 years old. There are much more current definitions if you wish to get that specific. But that still doesn’t mean that there are accepted and detailed definitions, because there aren’t any. There are lots and lots of definitions with minor differences — but that isn’t the same thing at all.
The really critical difference between the two forms of management is as follows: Watchful waiting is a means of monitoring men who one truly believes one will never have to treat because of their age, the slow change in their clinical status, etc., even if they have been diagnosed with advanced disease. Active surveillance, by comparison, is a process designed to monitor men who one is concerned that one certainly may have to treat while their disease is still localized to the prostate (which is why regular biopsies are commonly considered to be a critical feature of active surveillance protocols) in order to prevent the risk for clinically significant, progressive disease.