Stephan L. Werner, M.D., F.A.C.S. 

  Observation or "watchful waiting"   is usually not a term applied to cancer, for indeed it implies a willingness to allow the disease to progress unchecked, to some a sentence of death.  However, prostate cancer is a disease that may in some instances it may be appropriate to watch.  It frequently will not be the cause of death in patients with the disease, but late stage prostate cancer can be very painful and unpleasant.

    In general prostate cancer tends to be less aggressive with increasing age of onset.  Indeed, prostate cancer discovered when the patient is over 80 years of age tends to be slow growing, and is usually observed or watched, and treated only if the cancer seems to be growing aggressively.   Most physicians do not screen or obtain PSA examinations routinely on patients over 75.  If the digital rectal exam is stable there is not be an indication to do so.

   Over the past several years of aggressive prostate cancer detection and treatment it has been observed that for many men the risk of prostate cancer progression or death is limited, so that the risks and benefits of treatment become greater that the risks of the disease itself. Perhaps over 40% of men with prostate cancer may not need treatment initially or at all. The selection of these patients must be made carefully, and the patients must understand the risks of what we prefer to call Aggressive Observation.

    Patients over age 60 with a tiny amount of low grade, Gleason 6, PCa and a PSA <10 are the most appropriate candidates for aggressive observation, and many may never require treatment. Younger men with similar "low risk" prostate cancers may elect to undergo aggressive observation, knowing that the natural history of PCa is to become more aggressive over time. Men electing aggressive observation, thereby avoiding or delaying the potential risks of impotence, incontinence and other risks of prostate cancer treatment, must understand that they may require treatment at a later date, and may miss the window of opportunity for cure. A new test the PostatePX assessment of PCa aggressiveness may play a role in the decision, but data is not yet in.

    Patients with  other severe  medical conditions who are discovered to have prostate cancer may be best observed, and treated only if the prostate cancer is aggressive.  The patient with severe heart or lung disease, or another aggressive cancer or a different condition with a limited life expectancy will probably not be significantly affected by the prostate cancer unless it is high risk, or later stage and maybe not even then.   Careful medical evaluation and discussion is indicated.

     What is aggressive observation or watchful waiting?  Prostate cancer seems to become higher grade with time. Is one to do multiple biopsies over time, or just follow the PSA?  There is no standard protocol. At the minimum, PSA and digital rectal examinations should be done every three to six months, and rebiopsy done if prostate changes are found, the PSA rises, or at appropriate intervals, perhaps every two to three years. 

    A highly controversial issue is whether patients on aggressive observation should be put on a 5-alpha reeducate inhibitor, drugs that have been shown to inhibit the development of low grade prostate cancer, but have not yet been shown to delay its progression. There is currently no indications to do so.

    The decision to observe patients with prostate cancer must be made by an compliant, informed patient, who understands that he may not be curable if and when he desires to change his mind.

Rev: 03/09

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Rev:03/08