July 26th, 2010
05:59 PM ET

Low-risk prostate cancer gets aggressive therapy

Most men diagnosed with prostate cancer are undergoing aggressive treatment even if their prostate-specific antigen (PSA) level and risk of disease are actually low, a new study found.
PSA is a protein made in the prostate gland. It's normal for men to have a small amount of this protein in their blood, but elevated levels could be a sign of cancer or other prostate disease. Typically a PSA level below 4.0 nanograms per milliliter is considered normal and that number is used to determine whether a biopsy or further testing is necessary.

In a report in the Archives of Internal Medicine researchers looked at risk and treatment patterns of nearly 124,000 men that had just been diagnosed with prostate cancer between 2004 and 2006. Fourteen percent had PSAs 4.0 nanograms per milliliter or below. Fifty-four percent of those had low-risk disease–stage II or lower–yet prostatectomy or radiation therapy was the treatment chosen for 75 percent of the group.

"It is clear from our current study that men are choosing aggressive forms of treatment when they may not need to. This is especially concerning for older men, as previous studies done by our team show excellent disease-specific survival for men with low-risk cancer following conservative management," says Dr. Grace Lu-Yao, senior author and cancer epidemiologist at the Cancer Institute of New Jersey. "Because this is the most comprehensive study of U.S. men in this population to date, we anticipate that these results will help both physicians and patients more closely examine a man's treatment needs."

One-third to 70 percent of men who are diagnosed with prostate cancer through screening get treatment that they don't need, according to Dr. Otis Brawley, chief medical officer at the American Cancer Society. "Over the last 10 years it has progressively become more popular, if you have a low-grade prostate cancer there's a movement toward watching it and after active observation over several years if it seems to be growing, to treat it," Brawley says. " If is seems not to be growing, to continue active observation–or what use to be called watchful waiting."  He adds:  "This study is actually important because it shows that there's a whole bunch of men who have gotten very aggressive treatment for prostate cancer who should have gotten watchful waiting."

Brawley says robust data how that breast, cervical and colon cancer screening and early detection saves lives, but no such data exist for prostate cancer.

Researchers have discussed lowering the the PSA level to 2.5. But Lu-Yao says that could result in even more unnecessary treatments. "Because the inability still exists to determine whether prostate cancers are slow growing or aggressive, lowering the PSA threshold might increase the risk of overdiagnosis, which could lead to treatment that holds no benefit for the patient or could have adverse side effects."

It's a complicated issue that needs more studies, says study co-author Dr. Mark Stein. "There are men in the low-risk category who aren't low risk.  We need better ways of teasing out who that is. You don't want to undertreat people either. This article does not say having a PSA of less than 4 is necessarily safe, that there is no such thing as high risk aggressive cancer in that population. You can have more aggressive tumors in that range, so there is that double-edge problem."

Stein says another problem is telling someone they have cancer that shouldn't be treated, just watched. "In the United States, it's hard to tell people you have cancer and you are not going to do anything about it."  Brawley agrees. "We have data that proves that the suicide rate is higher among men who are being watched than among that same age group of men who have not been screened or diagnosed."

soundoff (7 Responses)
  1. charles tosi

    Hi, my PSA was 4.3 , 6 months later jumped to 7.2. I requested a byopsy, results were: prostate cancer with a Gleason 10, now what do I do??? Charles

    July 26, 2010 at 23:26 | Report abuse | Reply
    • Terri

      Charles, my husband (47 at the time) had a Gleason of 9 and chose a radical prostectomy using the DaVincci Robotic method. He did have a chest xray, full radioactive bone scan, and an endorectal coil MRI (NOT comfortable) prior to his surgery, all of which indicated the cancer had neither metastasized nor broken the prostate barrier, though it was VERY close. The DaVincci was far less invasive, had a much faster recovery (2 weeks vs 6 weeks), did a fairly good job of preserving the nerve bundles necessary to achieve erection. And (in part due to his young age), he also maintained continence within a few weeks of his surgery. They did find that the cancer was contained w/in the prostate but found trace amounts of cancer cells in one of the 8 lymph nodes they removed However both the 3 and 6 month follow up PSA tests are undetectable. Do your homework, find a good doctor in your area that you trust and ASK QUESTIONS! Its scary as hell and will change your life. It will affect your marriage / relationship, so be open with your partner. Good Luck and may God be with you and your family!

      July 27, 2010 at 17:21 | Report abuse |
  2. Ames

    People are getting aggressive treatment because they do not want to die from prostate cancer. I mean, really, is that not the obvious reason? And I would do the same thing. My father in law was told to practice "watchful waiting" and his PSA continued to rise. He was treated with radiation and yet the cancer spread throughout his body and he died. His doctors never told him that if you receive radiation therapy that removal of the prostate is no longer an option. Had he known this, he likely would have just had the prostate removed and might still be alive today.

    July 27, 2010 at 23:23 | Report abuse | Reply
    • Arthur

      Ames, First this is not true. Radiation is frequently used as salvage therapy after the PSA rises after the prostate is removed or there is microscopic prostate cancer remaining.

      Also, your father was mis-informed if he was told that the prostate could not be removed after radiation therapy. Most university hospitals will remove the prostate after radiation therapy, if there is no evidence of distant spread. Please check with the Memorial Sloan Kettering Cancer Center in New York, Karmanos Cancer Institute in Detroit, Johns Hopkins or other centers. The surgery is more complex, but is performed and well reported.

      Likewise, radiation therapy is also an option after prostatectomy, although it is more difficult to deliver and has more side effects, but both treatments are effective as primary and as salvage, if the first choice fails. While there are no studies that directly compare head to head radiation therapy against prostatectomy, there have been many studies that look at similar cases that compared outcomes of those treated with radiation or with surgery. Both appear to be equally effective in lower risk prostate cancer and radiation therapy may have an edge in high risk prostate cancer, as high risk prostate cancer is more likely to be outside the capsule surrounding the prostate or in the lymph nodes. A study in Sweden many years ago looked at "watchful waiting" vs. treatment and found that treated men did better. Generally if you are healthy and can expect to live more than 8 years, you should have a frank discussion with your family doctor, a radiation oncologist and a urologist. Each have biases and it is important to get a balanced view of what each can and cannot do.

      Unfortunately, in some cases, no matter what we do, sometimes the cancer does recur and spread. My condolences to you and your family.

      July 28, 2010 at 08:46 | Report abuse |
  3. Prostate cancer surgery

    All this started just sufficient. The doctor got my blood pressure as well as seemed satisfied with the result. He or she inquired with regards to our our health and wellbeing after which it said "perhaps you have had a …prostate cancer

    January 25, 2012 at 21:59 | Report abuse | Reply
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