Study shows watchful waiting for prostate cancer popular among veterans

A recent study published in the Journal of the American Medical Association found that watchful waiting or active surveillance is the preferred method of treatment among veterans diagnosed with low-risk or nonaggressive prostate cancer. The number one cancer for men who seek healthcare at Veterans Affairs (VA) hospitals across the United States is prostate cancer. 

This news is one more study out of many that have consistently shown that men with low-risk prostate cancer can have a favorable outcome without surgery or other invasive means of treating the disease.  However, the United States has been slower to utilize watchful waiting when compared to other countries.  Financial incentives and medicolegal concerns have been primary barriers by U.S. doctors using watchful waiting as a legitimate way of keeping an eye on a nonaggressive and slow growing prostate tumor.

What is watchful waiting or active surveillance?

Prostate cancer found in men growing very slowly, may never need to be treated.  Instead, an approach a doctor may use in this circumstance is called active surveillance or watchful waiting.

Not all doctors use the terms active surveillance or watchful waiting synonymously or use them the same way.  Some doctors feel using the term “watchful waiting” means nothing is being done but that is not true.  Other doctors do use the two terms interchangeably to mean the same thing. 

Active surveillance means to monitor the cancer closely where the doctor may do a prostate specific antigen blood test (PSA) and a digital rectal exam either every six months or yearly.  Watchful waiting may mean a less intensive type of follow-up relying on fewer tests and relying more on changes in a man’s symptoms deciding then if treatment is needed.

Whether a doctor decides to call it active surveillance or watchful waiting, either way, men with prostate cancer may be advised to choose this method if they have:

·      A small tumor that’s confined to the prostate

·      A slow-growing cancer

·      A low risk that the cancer will grow locally or spread (metastasize) or that a man will die from the disease

Many men determined to have low-grade cancer and are considered to be at a low risk of the cancer spreading, may be given this option by his doctor.  Men should understand that active surveillance is still considered a form of treatment and he will still be seen regularly by his doctor.  More aggressive forms of treatment such as surgery or radiation will not be used as the tumor is not considered life-threatening or is at a low risk of spreading or getting worse.

Study results

Researchers from the New York University School of Medicine and the Manhattan campus of the Department of Veterans Affairs New York Harbor Healthcare System recruited 125,000 veterans (the largest study of its kind) diagnosed with nonaggressive prostate cancer between 2005 and 2015. In 2005, it was discovered that only 27 percent of men under age 65 opted for watchful waiting to keep track of their prostate cancer.  By 2015, this had reversed to where 72 percent chose to simply monitor their cancer but not treat it. 

This same study also reviewed a new genetic testing that would enable doctors to give patients a more specific diagnosis for their cancer.

Doctors who support watchful waiting or active surveillance are hopeful that more physicians across the country begin to see the value in using this method of treatment for men with a nonaggressive or low-risk prostate cancer.  The researchers want both medical professionals and men diagnosed with prostate cancer themselves to know that watchful waiting is neither irresponsible or dangerous as long as there is consistent communication between the patient and their doctor with regular check-ups.

It has been found that up to two-thirds of prostate cancer patients at low risk are still unnecessarily undergoing early aggressive treatment such as surgery.  The National Cancer Institute estimates that 29,000 American men will die from prostate cancer in 2018 with 164,000 new cases diagnosed, with most of these cases found in their earliest stages.

The VA and prostate cancer

The VA has become a leader in providing improved prostate cancer care spearheaded by former VA Secretary David Shulkin, The objective by the VA has been to build the most contemporary and advanced approach to prostate cancer by a more personalized approach beginning with a full assessment of a veteran, including genomic testing.  This approach means that not all men who receive a prostate cancer diagnosis will be treated the same.  Some men may require targeted chemotherapy and advanced cellular therapies, others may need surgery or radiation, and for other men with low-risk prostate cancer, it may mean using watchful waiting and avoiding the more aggressive treatments altogether.

Shulkin is the person who “jump-started” the precision oncology program at the VA.  Shulkin also advanced the VA partnership with the Prostate Cancer Foundation which led to a $50 million collaboration on precision oncology for prostate cancer.  This has also led to using IBM Watson to help with genomic analyses and a cancer survivorship genomic analysis program with Sanford Health.

The research study on veterans and prostate cancer could lead to possible major medical breakthroughs.  The emphasis has been on using men who have served their country and to show how precision oncology should be practiced.

It is recommended that all men beginning at age 40, have a baseline prostate specific antigen (PSA) test.  It is known that men as young as 40 can get prostate cancer and if they do it is often more aggressive. It has also been shown that waiting to screen men until the age of 50 or older can result in missing an early diagnosis.  When there is a delay in diagnosing prostate cancer, this only leads to an advanced stage of the disease when it finally is discovered where it may have already metastasized complicating treatment and the outcome.