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How should I handle an early cancer diagnosis?

How should I handle an early cancer diagnosis?

Updated: 12/21/2015

In the past, most patients diagnosed with prostate cancer had advanced disease. Today, 90 percent of patients diagnosed with prostate cancer have clinically localized disease, according to the National Cancer Institute. And the American Cancer Society reports that the five-year relative survival rate for patients with localized disease is nearly 100 percent.

PSA testing has helped spot cancer in its earliest, most curable stages. However, as with other cancer screenings, some cancers are detected at such an early stage that they don't need to be treated. They are simply too small and slow-growing to justify treatment.

During a biopsy to investigate an elevated PSA level, some doctors find minuscule amounts of cancer (smaller than 0.2 cubic centimeters) in their patients. For some men, these cancers will never cause harm, and ideally, should never have been diagnosed. But now that you know, this information creates a serious dilemma. How should you handle a small-volume cancer diagnosis? Should you have surgery or allow time to pass before taking action?

Important Guidelines for Early Prostate Cancer Assessment

Jonathan Epstein, M.D., developed guidelines for treating early prostate cancer. In addition to these guidelines, physicians must consider the patient’s age. For a man in his thirties, forties or fifties, a very small tumor might be significant. For a man in his sixties, a very small tumor isn't very significant, considering the time it takes for that tumor to grow and become dangerous.

Even without treatment, it can take more than 10 years for cancer that is fairly well differentiated (meaning that the cancer cells appear normal to the pathologist), with a Gleason score of 6 or less, and that is localized to the prostate to spread and cause harm.

Study Puts Guidelines into Practice

For several years, Dr. Epstein and H. Ballentine Carter, M.D. have been studying expectant management in men with stage T1c disease. Their results, published in The Journal of Urology, along with Patrick C. Walsh, M.D., and Patricia Landis, B.S., were very encouraging.

This study followed 81 men who fulfilled the criteria for low-volume disease. At an average two-year follow-up, 25 patients (31 percent) experienced disease progression. In 22 of these cases, every follow-up biopsy showed cancer. In patients who experienced cancer progression, their PSA density was significantly greater while their free PSA was less. Thirteen of these men underwent radical prostatectomy, and 12 patients (92 percent) had curable disease.

No Evidence that Cancer Grade Worsens within 24 Months

Most importantly, the research at Johns Hopkins Medicine revealed that there is no evidence that the prostate cancer grade worsens significantly between 18 and 24 months after biopsy. If your tumor grade changes relatively soon after biopsy, it's most likely not because the tumor evolved, but because the higher grade component of the cancer was missed.

Getting Started with Expectant Management

If you think you might be a candidate for expectant management of your early prostate cancer, take the following steps:

  • Have your pathology slides reviewed at Johns Hopkins Medicine. If the pathologist thinks you are still a candidate, he or she will repeat the biopsy and take at least 12 samples. If the repeat biopsy confirms that the cancer is low volume, you should return to Johns Hopkins Medicine every six months for a PSA test and a rectal exam. You should also have a follow-up biopsy each year.
  • If the repeat biopsy is negative, it almost certainly means that the cancer is truly tiny, and the initial biopsy just happened to hit some of its few cells. Collecting a history of negative biopsies helps confirm that the initial discovery was small-volume cancer.

Choosing Treatment in the Wake of Uncertainty

The study has expanded to include more than 200 patients. With an increase in test subjects, Dr. Carter has noticed the wide variability in the comfort levels of patients. Some patients choose to get treatment, even though there is no evidence of serious cancer, because they don't like uncertainty. This anxiety could decrease their quality of life. Still other patients are very comfortable with expectant management.

Studies are still being done to confirm the long-term results of expectant management. Researchers at Johns Hopkins Medicine remain excited about the potential to save a lot of patients from unnecessary surgery.


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