Our Greatest Wealth Is Health

Andrew Siegel MD  1/23/2021

THE CONUNDRUM

Prostate cancer reflects a broad range of biology and clinical risk and its management needs to be appropriately tailored to balance the risk of disease progression with the risks of side effects of treatment.

The million-dollar question for men with localized prostate cancer: Do you want to be treated for prostate cancer and reap the benefits of increased survival and longevity, but also possibly incur the risks and compromises that may interfere with your quality of life, often sexual and urinary side effects?

This is the conundrum that many men with localized prostate cancer face. How does one weigh the trade-offs and arrive at a rational decision about the best course to pursue, whether it is active surveillance, surgery, radiation, or focal ablative therapies? “Shared decision making” is the term applied to the collaborative process of arriving at decision, a choice that is ultimately made by the patient with the physician providing guidance and direction. 

TRIAGE AND RISK CATEGORIZATION

Years ago, virtually all men with newly diagnosed prostate cancer underwent radical prostatectomy. Since that time, urology has evolved tremendously and urologists are now much more nuanced and sophisticated in terms of ability to discern who needs active treatment and who does not based upon a number of factors.

Triage prioritizes treatment by the severity of the disease and likelihood of recovery with and without treatment. Newly diagnosed prostate cancer is categorized by disease severity into the following risk categories:

• Very low risk
• Low risk
• Favorable intermediate risk
• Unfavorable intermediate risk
• High risk
• Very high risk

Very low risk and low risk prostate cancer can be readily and safely managed with rigorous monitoring and regular follow-ups without surgery, radiation, or any form of treatment, a strategy known as active surveillance. Unfavorable intermediate risk, high risk, very high prostate cancer risk merit active treatment. The “grayest” area is the favorable intermediate risk category.  

WEIGHING SURVIVAL VERSUS TREATMENT-RELATED SIDE EFFECTS

Navigating the trade-offs between the pluses and minuses of prostate cancer treatment options is challenging for urologists and patients alike. This is particularly difficult with localized prostate cancer since the outcomes among the various options are often similar, although the side effect profile is more variable. Patients with localized prostate cancer have a choice between active surveillance and active treatments (surgery, radiation, androgen deprivation, focal therapies). Active treatments increase survival and longevity, but also escalate possible intimate issue side effects including urinary control and erectile/ejaculatory function.  How does one prioritize the strengths and weaknesses of any particular treatment and make treatment choices?

A recent article in the Journal of Urology by Watson et al addressed this issue (Vol 204, Aug. 2020, 273-280), evaluating and quantifying the trade-offs between active surveillance and active treatments in more than 600 men with newly diagnosed localized prostate cancer. “Discrete choice experiments” (originating in mathematical psychology and economics) were used to predict individual choices. The study found that men with favorable intermediate risk prostate cancer are willing to accept up to a 10% or so survival disadvantage over 10-15 years in order to preserve urinary and sexual function. The study showed that even patients with high risk prostate cancer are willing to accept a decrease in survival for faster recovery and functional improvements.

Men desire to be cured of prostate cancer, but also wish to retain urinary control and sexual function. When performed by highly skilled and experienced urologists, the vast majority of patients fare extremely well with minimal side effects from robotic assisted laparoscopic prostatectomy. However, even in the best of hands, not every patient will achieve “trifecta” status: undetectable PSA, full urinary control, and satisfactory erections. The key point is that side effects and complications are important to patients and need to be carefully weighed into the treatment decision making process.

“Complications are the patient’s perceptions, and for the patient, perception is reality.”

–Dr. Richard Williams

Bottom Line: Typically, the discussion with the newly diagnosed prostate cancer patient explains the various treatment options that offer a survival benefit (quantity of life) and their potential urinary and sexual functional side effects (quality of life).  Urologists rarely discuss this from the reverse perspective—asking patients what survival benefits might be traded off to preserve function. Patients with favorable intermediate risk disease are the particular category of patients that may prefer active surveillance to active treatment and may be willing to assume the possible risk of a survival disadvantage. 

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.  Today’s entry is excerpted from his latest book, Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Video on THE KEGEL FIX

Tags: Andrew Siegel MD, prostate cancer, Prostate Cancer 20/20, prostate cancer risk categorization

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