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Why is Nobody Treating My Prostate Cancer?

Many men are going with active surveillance–and that’s a good thing.

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Dear Doctor,

I was recently diagnosed with prostate cancer, and it felt like my world was turned upside down. I’ve always been a pretty healthy guy (I eat well and exercise), and it feels unsettling to know there are cancer cells trespassing in my body. I was eager to hear what my treatment would be—only to learn that my doctor doesn’t recommend any treatment at all. What gives?! Should I be worried that my doctor isn’t doing anything about my cancer?


"Man Without a Plan"

Dear Man Without a Plan:

I’m sorry to hear about your diagnosis. Learning that you have cancer can trigger a roller coaster of emotions, all normal.  Most of us are used to the idea that a cancer diagnosis is promptly followed by a plan to annihilate the disease. But prostate cancer is often an exception. It operates differently than many other cancers due to its dual-faced nature. It’s sort of like "Dr. Jekyll and Mr. Hyde," where in some cases it is extraordinarily slow growing and unlikely to cause any harm, and in other cases it is quite lethal.

That’s why the first step is to figure out the severity of your cancer and the risk of it spreading and causing serious illness and/or death. Your doctor probably used various tools (like PSA test/biopsy results, family history, physical examination, MRI and sometimes other urinary and blood-based markers) to determine the extent of your cancer and whether you are at very low, low, intermediate or high risk for the disease to spread. Your doctor must have determined that you are in either the very low risk, or low-risk groups.

And here’s the surprising part—most very low and low-risk prostate cancer patients do not require active treatment. I know that sounds counterintuitive, but in many cases, the cancer does not actually pose much threat. So instead of inundating you with radiation and surgery and the potential side effects that come with these treatments, your physician has opted for a technique called “active surveillance.”

How does it work? You will be closely monitored with physical examination and blood tests typically every six months, and either an MRI scan and/or additional biopsy typically about once per year.  If your prostate cancer continues to be small, slow-growing and nonthreatening, then the surveillance continues while you enjoy a normal, happy and otherwise healthy life. If your test results change, then your doctor will talk to you about stepping up treatment.

It might make you feel better to know that active surveillance is not a new trend—it’s been around for many years. But we’re embracing it much more frequently than we have in the past. Ten or 15 years ago, a lot of men with low-risk, even very low-risk, prostate cancer endured radiation and surgery, but doctors now know that active surveillance can be just as effective for many men—and spare them the side effects and complications that can come from aggressive treatment.

In fact, most of the patients I treat with low-risk prostate cancer are doing active surveillance. Overall, I’d say a solid third of my patients are taking this more conservative approach, so trust me, you are not alone! The growing popularity of active surveillance reflects a much more informed and evolved approach to prostate cancer—we’re getting better at treating those who need treatment and are able to avoid overtreating the men who don't.

So to answer your question: There’s no need to worry that your cancer is being undertreated, and it is certainly not being ignored. You, and the cancer, will be followed very closely.  In pursuing active surveillance, you’re actually taking advantage of the latest scientific knowledge. You will come to find that your diagnosis is much more of a mental battle than a physical one, and you just need to give yourself some time to adjust.

“Your diagnosis is much more of a mental battle than a physical one.”
Dr. Lee Richstone, chief of urology at North Shore University Hospital
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Published June 19th, 2018
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