There were approximately 165,000 new prostate cancers diagnosed last year in the United States. During the same time period, there were 29,000 deaths from prostate cancer. The deaths were almost entirely due to highly aggressive forms of the disease. Most of the patients with less aggressive forms of the disease will die of other causes before the prostate cancer can kill them.
One of the great dilemmas in prostate cancer medicine is whether and when to test and, if testing is positive, whether to treat or to watch and wait. Of the 165,000 new prostate cancer patients, most will choose to have one of the three definitive treatments: removal of the prostate (prostatectomy), direct radiation, or insertion of radioactive pellets into the area of the prostate (brachytherapy). Not only are these treatments expensive, men who have had any one of the three have a less than 50% chance of being able to have a functional erection in the future. They are also at significant risk for urinary problems such as having to urinate frequently (frequency), having to urinate right now (urgency), and not being able to control their urine (urinary incontinence). When these side effects are present, most men will say they do not have a good quality of life. Since aggressive fatal prostate cancers are only about 20% of the total, many of the remaining 80% are being overtreated – to their great detriment.
Fortunately, medicine is getting better and better at identifying the aggressive cancers and differentiating them from the less aggressive ones, which can be safely monitored. Genomics tests, which have been used with great success in identifying aggressive breast cancer tumors, are being used to identify aggressive prostate cancers, but their success rate is not quite as good as it is in breast cancer. Even with these limitations, the use of genomics testing has reduced the number of patients with low or intermediate grades of prostate cancer who choose to undergo one of the three definitive treatments.
While it is important for men at risk to be tested for prostate cancer, a positive result alone should not mean treatment, much less one of the three definitive treatments. For most men, active surveillance will be the appropriate course. Should the cancer turn aggressive, the option for definitive treatment can be exercised. In the meantime, the patient’s quality of life can remain good. As always, talk to your doctor but be a knowledgeable consumer of the health care they are selling.