The psychology of prostate cancers

The psychology of prostate cancer treatment

Important news for men with prostate cancer: first, the cancer tends to grow so slowly that only a fraction of patients actually die from it.

Second, men with low-grade cancer who opt for close monitoring instead of surgery to remove the prostate do not seem to suffer anxiety and distress from living with cancer.

Prostate cancer, the second most common cancer in men after lung cancer, is increasingly being diagnosed at earlier stages, mainly because of more widespread screening programs. While many prostate tumors grow very slowly and take years to cause harm, many men nevertheless undergo aggressive surgery and radiation, and end up living with the side effects of treatment -- including impotence and incontinence -- for a cancer that may never have killed them.

Dr. Peter Scardino of Memorial Sloan-Kettering Cancer Center in New York and colleagues studied more than 12,600 men with prostate cancer, including some with a particularly aggressive form. All the men had their prostates removed. In the Journal of Clinical Oncology, the researchers report that 15 years later, only 12 percent had died from cancer. On the other hand, 38 percent had died from other causes.

The study "shows a remarkably low risk of dying of prostate cancer within 15 years for treated men, and supports the concept that men with slow-growing cancers may not need immediate treatment," said Scardino.

However, in the United States, less than 2 percent of men under age 65 with prostate cancer choose "watchful waiting," according to Dr. Scardino and colleagues.

In a separate study, Dr. Roderick C. N. van den Bergh at Erasmus University Medical Center in Rotterdam, the Netherlands and colleagues questioned 150 men with low-grade prostate cancer who did opt for watchful waiting, also referred to as "active surveillance." In active surveillance, patients can undergo treatments if and when the disease worsens. Surprisingly, most of the active surveillance patients were less conflicted about their decisions, less depressed and less anxious.

The cause-effect is a bit murky, of course: Dr. van den Bergh admitted that it's possible the men in the study were able to choose the active surveillance approach "because they tend to suffer less anxiety and distress." Even so, he said, "The take-home message is that men with a supposedly low-risk form of prostate cancer who chose active surveillance instead of radical treatment do not seem to show increased levels of anxiety and distress when compared to men who receive other forms of treatment (like surgery or radiation."

"This potential psychological burden was supposed to be a major disadvantage of active surveillance," Dr. van den Bergh continued. "Active surveillance seems therefore to be a feasible option with regards to anxiety and distress issues."

SOURCES: Journal of Clinical Oncology, July 27, 2009, and Cancer, September 1, 2009

Dr. Cinque's comments: I am glad to hear that men usually hold up quite well psychologically, even as they live with untreated prostate cancer. Of course, even if they pass on radical treatment, it doesn't mean that they have to do nothing. They can still address all the many dietary, nutritional, and lifestyle factors that will increase their chances of surviving for a long time with prostate cancer. And I think that most men in that situation take their psychological cues from their doctors. If their doctor is cool, they are going to be cool. So, I am hoping that more doctors will support the idea of putting off radical treatment for prostate cancer in the usual cases. There is simply no convincing evidence that radical intervention prolongs life, and it certainly does not enhance the quality of life. So, the rule should be: don't disturb prostate cancers that seem to be the quiet, non-aggressive form. And if they are not sure, if it were me, I would still err on the side of restraint.
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