It took eight agonizing months for Charles Linzey to decide how to treat his early-stage prostate cancer. His wife, in contrast, had her early-stage breast cancer surgically removed just a month after diagnosis.
It’s not that the Baltimore businessman was less decisive. Instead, Linzey ran into a distressing reality: Unlike with breast cancer and many other malignancies, doctors simply couldn’t tell him which therapy was a better bet for the leading male cancer.
There is little good research directly comparing prostate treatment options to help the newly diagnosed choose between surgery, two types of radiation, or watching a small tumor to see if it needs treating at all.
“I never felt comfortable, even when I made my choice, with my choice. Because no one would say, ’That’s a good choice,”’ says Linzey, 59, who ultimately went with implanted radioactive “seeds” and is faring well.
Two new studies suggest the advice gap has consequences: overtreating early-stage tumors, and therapy choices driven by fear and misperceptions.
“When we give people choices, it’s sometimes more difficult,” acknowledges Dr. John B. Fiveash, a radiation oncologist at the University of Alabama, Birmingham, who is at the forefront of a fledgling trend to try to change that — through specialized prostate clinics.
Key for patients to know: “Not all prostate cancer is the same,” stresses Dr. John T. Wei, a University of Michigan urologist who recently reported that about 55 percent of men with low-risk tumors are overtreated, unnecessarily exposing them to such side effects as impotence and incontinence.
Certainly aggressive prostate cancer can kill. But often, prostate cancer is so slow-growing, and discovered when it’s so small, that men will die of something else before it ever causes symptoms, much less becomes life-threatening.
One man in every six will get prostate cancer, but only one in 34 will die of it, the American Cancer Society says.
That sounds reassuring until you’re the man wondering if you’ll be in the lucky majority or not. Unfortunately, doctors have no easy way to tell.
Adding to the confusion: Studies are contradictory about whether aggressive treatment really improves a low-risk man’s long-term chances of survival — or if a better option might be to closely monitor the tumor and treat it only if it starts to grow, so that he doesn’t endure side effects until he really has to.
And while some older studies do suggest that radiation and surgery recipients fare equally well for up to 10 years, Fiveash laments that there are no direct comparisons of more modern surgical and radiation techniques, including more precisely targeted, potentially safer ways to deliver radiation.
So doctors typically just present all the options and let men choose.
Michigan’s Wei and colleagues tracked more than 64,000 men deemed so low-risk that they were good candidates for what’s dubbed “active waiting” instead of immediate treatment. Those over 70 were most likely to be unnecessarily treated, he reports this month in the Journal of the National Cancer Institute.
How do men choose? University of Colorado researchers interviewed 20 newly diagnosed patients just after a doctor explained their options. More than half wanted treatment as fast as possible; they were too frightened to wait even for a second opinion, the researchers recently reported in the journal Cancer.
More troubling were the myths. Some called removing a cancerous prostate a guarantee for a cure — it’s not — while others opted for radiation because they wrongly thought only surgery could cause impotence. In fact, men were more likely to follow a friend’s recommendation than to compare the limited scientific data on treatment side effects and benefits.
To help men make more educated choices, UAB and Michigan head a small but growing number of cancer centers that offer “multidisciplinary prostate cancer clinics.” Modeled on the one-stop consultations long available to breast cancer patients, men can see, in one visit, urologists, radiation oncologists and other specialists, to compare their options with proponents of each.
And Wei and the Michigan Cancer Consortium developed a Web site — www.prostatecancerdecision.org — that presents what scientific data is available for each therapy at a 6th-grade reading level, for a side-by-side comparison.
Linzey, the Baltimore man, recalls his frustration as specialists quickly laid out the top option for his wife’s breast cancer at the same time he was searching out doctors to debate the pros and cons of prostate treatment.
“It’s a shame there is no right answer,” says Linzey, whose tests suggest his cancer is gone three years after he settled on seed implants. He gets regular checks, so even if it returns, “the chances of it killing me are pretty slim.”