Over-Treating Prostate Cancer

Do some men receive treatment for prostate cancer that they don't need? Absolutely, says urologist H. Ballentine Carter, M.D., whose pioneering "Active Surveillance" program of rigorous monitoring has set the standard for helping some carefully selected men with small-volume, slow-growing prostate cancer put off, or avoid altogether, surgery or radiation therapy. Carter has also dedicated the last two decades of his career to learning the intricacies of PSA ; he coined the term "PSA velocity" – a means of watching PSA 's rise over time, and understanding when its pace might signal cancer. At the same time, it was Carter's research that discovered that men with very low PSA levels can have highrisk cancer, that men who are in the Active Surveillance program need periodic biopsies every one to two years – and that even then, there is no guarantee that cancer might not somehow slip outside the prostate.

Carter tries very hard to find balance between treating prostate cancer that probably isn't going to cause trouble, and not treating cancer that shows signs of becoming dangerous. His work is more important than ever, with the U.S. Preventive Services Task Force's recent recommendation that men don't need PSA screening (see story), and the PIVOT investigators advising against surgery (see story). Also, "the National Institutes of Health convened a State of the Science conference to address the topic of active surveillance as a means of reducing prostate cancer over-treatment, and concluded that this approach is underutilized today," he notes. "Most experts, regardless of their perspective, agree that over-treatment of prostate cancer needs to be addressed." Carter believes the answer lies in an individualized approach to patient care. In two articles recently published in the Journal of Urology, he shared what he and colleagues have found.

The ultimate choice for treatment depends
on a man's personal preferences.
"Would you rather live knowing you have cancer,
or would you rather put up
with the possible side effects of treatment?

Low-Risk Prostate Cancer What is low-risk prostate cancer? It either is a very small nodule, or is too tiny even to be felt on a digital rectal exam; its Gleason score is 6 or less; and it's associated with a PSA lower than 10 ng/ml. Working with Carter, David Liu, who is training to be a medical oncologist, designed a computer model to compare the effectiveness of surgery or active surveillance in men with low-risk prostate cancer. He looked at the years of life gained, and also the quality of those extra years based on potential side effects of treatment – a measure called "Quality-Adjusted Life Years" (QALY). "David found that for men up to 74 years who were in excellent health, surgery was preferable," (with greater QALYs), Carter explains. "But for men in poor health over age 54, surveillance was preferable. For men in average health, who make up half of the population, surveillance was preferable over age 67." Still, he adds, the ultimate choice depends on a man's personal preferences.

"Would you rather live knowing you have cancer, or would you rather put up with the possible side effects of treatment? Since 90 percent of men in the U.S. who are diagnosed undergo some type of treatment for their cancer, these findings suggest that a large proportion of men should consider their choice carefully. This study helps men make a more informed choice."

Should the Treatment be Surgery?
In the second publication, Carter worked with Jeff Mullins, a urology resident. "Jeff set out to determine what proportion of men undergoing surgery at Johns Hopkins had a diagnosis of low-risk prostate cancer. Looking back from 1983 to 2010, he found that only 8 percent of the more than 19,000 radical prostatectomies performed were in men over age 65 with low risk prostate cancer," Carter says. About one in three of these 8 percent turned out, after the pathologist examined the prostate specimen, to have more extensive disease than the surgeon expected based on the biopsy, PSA , and rectal exam. "These are the men more likely to have benefited from an operation," says Carter. But in contrast to our experience at Johns Hopkins, in the U.S., instead of 8 percent, about 40 percent of men between ages 65 and 74 with lowrisk prostate cancer undergo surgery. This probably reflects our view that older men with low-risk prostate cancer should carefully consider whether or not surgical treatment is necessary and the right choice for them.

This year, Carter was elected to the Board of Trustees of the American Board of Urology. This distinguished organization has the responsibility of protecting the public, ensuring the high-quality, safe, efficient and ethical practice of urology by establishing and maintaining standards of certification for urologists.

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