In 2012, a survey from the Mayo Clinic and Harvard was sent to 1,439 physicians. The conclusion was that even though active surveillance is widely viewed as effective, most urologists continue to recommend surgery, while most radiation oncologists recommend radiation therapy. Why are so many doctors continuing to be lukewarm about active surveillance? Here are some thoughts:
- Never in the history of mankind has cancer been watched rather than treated. Adapting to this radical new way of thinking takes time. Doctors are fearful because they would face a disastrous lawsuit if the cancer was ever to spread.
- The medical world is rapidly changing. Doctors struggle to find time to stay abreast of all the changes. Due to a lack of knowledge, many doctors remain unconvinced that active surveillance is a safe approach.
- Due to the short nature of a typical doctor visit, it is challenging for doctors to find enough time to teach patients about why active surveillance makes sense.
- All things being equal, doctors would prefer to give patients what they want. Patients who are newly diagnosed with cancer are naturally looking to treat their cancer.
- Treatment pays doctors far better than observation.
The medical community fumbled badly in the 1960s when it labeled Gleason 6 a “cancer.” Now we know that Gleason 6 never metastasizes. Therefore, it fails to meet even the minimum requirement of being defined as a cancer. Despite an abundance of scientific support for active surveillance many doctors and patients are still unconvinced. In their frightened state, patients don’t count the cost of having lifelong, irreversible side effects from treatment. The rarely receive emotional support from their doctors and without intensive reeducation, they struggle to overcome their preconceived ideas about the deadliness of cancer. In addition to all of this, family members are also frightened and tend to insist on treatment. It’s no wonder that many men are attracted to surgery. They believe that cutting out the prostate will bring them relief from all the emotional uncertainty.
The Drawbacks of Active Surveillance
The biggest concern for men contemplating active surveillance is that the initial random biopsy may have missed a higher-grade tumor. Most centers address this problem by doing random biopsies every couple of years, which are unpleasant, can cause serious infections, increase the risk of impotence, and worsen urinary symptoms. Thankfully, recent studies now show that multiparametric MRI (Chapter 4) is an excellent alternative to having repeated random biopsies.
Living with Cancer
Anxiety and uncertainty about living with untreated “cancer” is certainly a problem. Some degree of anxiety, however, is inescapable no matter what treatment approach is selected. Studies show that men who had surgery or radiation also struggle with fears that the cancer may come back. Men in Sky need to guard against rushing into unnecessary treatment. Too often their treatment ends up being associated with irreversible side effects.
Now that patients with Sky have finished this Section, they can skip ahead to Chapter 43 to complete the remainder of the book.
Mark Scholz, MD is the Executive Director of the Prostate Cancer Research Institute. He is also the Medical Director of Prostate Oncology Specialists Inc. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is co-author of Invasion of the Prostate Snatchers. He has authored over 20 scientific publications related to the treatment of prostate cancer.