Prostate cancer is one of the most common cancers in men, especially as they get older. Over 60% of prostate cancer cases occur in men over 65 years old. However, despite being widespread, prostate cancer is often not a major focus for cancer researchers. The main reason? It usually grows very slowly, and most men diagnosed with prostate cancer end up dying from other causes rather than the cancer itself.
Over the past 15 years, doctors have increasingly adopted a strategy called “watchful waiting” or “active surveillance”. This means that instead of treating prostate cancer right away, doctors carefully monitor the patient’s condition through regular check-ups, blood tests, and biopsies. Treatment is only started if the cancer grows, or symptoms develop. This approach helps avoid unnecessary treatments and their potential side effects.
However, even though watchful waiting has become more common, there is still a concern about overtreatment. A recent study from the U.S. Department of Veterans Affairs (VA) health system found that while fewer men with low-risk prostate cancer are being aggressively treated, the number of men with intermediate- and high-risk prostate cancer who receive aggressive treatment has increased significantly. The study found that for intermediate-risk cases, aggressive treatment rose from 37.6% to 59.8%. For high-risk patients with an expected five-year life expectancy, treatment increased from 17.3% to 46.5%.
This means that many men may be getting unnecessary treatments, especially those who have other serious health conditions or a shorter life expectancy. Since more than half of men over 65 have a life expectancy of under 10 years, overtreatment can lead to unnecessary side effects without extending life.
Signs and Diagnosis of Prostate Cancer
Most men with early-stage prostate cancer do not experience any symptoms. This is why doctors often rely on screening tests to detect the disease.
The most common test for prostate cancer is the PSA (Prostate-Specific Antigen) blood test. If the PSA levels are high, the next step may be a prostate biopsy, or an MRI,which helps confirm if cancer is present. However, a high PSA level does not always mean cancer—sometimes, it could be caused by other conditions like benign prostatic hyperplasia (BPH), which is a non-cancerous swelling of the prostate.
If prostate cancer is found and confined to the prostate, the five-year survival rate is nearly 100%. This means that most men diagnosed early have a very high chance of living a normal life.
Treatment Options for Prostate Cancer
There are several options for treating prostate cancer, but not all men need immediate treatment. The most common approaches include:
1. Watchful Waiting (Active Surveillance)
For men with low-risk prostate cancer, doctors often recommend watchful waiting instead of immediate treatment. This involves:
Regular PSA tests
Occasional biopsies to check if the cancer is growing
Prostate MRi to check for growth
If the cancer does not grow or cause symptoms, no treatment is necessary. This approach helps men avoid unnecessary side effects from treatments like surgery or radiation.
2. Surgery (Prostatectomy)
If the cancer is aggressive or growing, surgery may be needed to remove the prostate gland. While surgery can be effective in eliminating cancer, it comes with risks, including:
Loss of bladder control (incontinence)
Erectile dysfunction (impotence)
Bleeding complications
Risk of infection
Anesthesia risk
These side effects may be temporary or permanent, depending on the patient’s age and overall health.
3. Radiation Therapy
Radiation therapy uses high-energy rays to kill cancer cells. There are two main types:
External beam radiation – A machine directs radiation at the prostate.
Brachytherapy – Small radioactive seeds are placed inside the prostate.
Radiation therapy is often as effective as surgery but may cause:
Urinary and bowel problems
Burning or bleeding in the bladder and rectum
Sexual dysfunction
4. Hormone Therapy
Since testosterone fuels prostate cancer growth, hormone therapy lowers testosterone levels to slow cancer progression. This treatment is usually used for advanced cancer or in cases where surgery and radiation are not options.
5. Chemotherapy and Newer Treatments
For prostate cancer that has spread beyond the prostate, chemotherapy may be used to kill cancer cells and slow down the disease. Other newer treatments, such as immunotherapy and targeted therapy, are also being researched.
The Role of Life Expectancy in Treatment Decisions
One major issue in prostate cancer treatment is overlooking life expectancy when making treatment decisions. According to Dr. Michael Leapman from Yale School of Medicine, many doctors do not use life expectancy calculators to determine whether treatment is necessary. Some doctors don’t bring it up because they assume patients don’t want to know how much time they have left.
At the San Francisco VA Health Care System, doctors have access to a multi-disease longevity calculator that helps estimate life expectancy. However, even when this information is available, many doctors struggle to have honest conversations with patients about whether aggressive treatment is really necessary.
The Importance of Shared Decision-Making
Thirty years ago, the concept of “shared decision-making” became an important part of prostate cancer treatment. This means that doctors and patients work together to make treatment decisions based on:
Medical facts
The patient’s values and personal preferences
However, in reality, many doctors still guide patients toward their own preferred treatment option rather than giving them all the facts. Studies show that the doctor’s recommendation is often the main factor in a patient’s decision.
Experts suggest that patients should talk to their primary care doctor before seeing a specialist like a urologist or radiation oncologist. Primary care doctors have a long-term relationship with the patient and may be more neutral in discussing the options.
Should You Get Screened for Prostate Cancer?
Screening for prostate cancer can reduce overtreatment if done thoughtfully. However, studies show that many older men are screened unnecessarily. For example, nearly half of men over 70—who are unlikely to benefit from treatment—still undergo screening.
The American Academy of Family Physicians (AAFP) and the U.S. Preventive Services Task Force actually recommend against routine PSA screening for all men because of the high risk of false positives and unnecessary treatment. Other organizations recommend screening between the ages of 50-69.
Experts suggest that men should:
Discuss screening with their doctor first
Get a second PSA test if the first one is high
Consider watchful waiting before agreeing to treatment
Key Takeaways
1. Prostate cancer is common but most often slow-growing – Most men die from other causes, not prostate cancer.
2. Watchful waiting is a safe option – Many men do not need immediate treatment.
3. Overtreatment is a big issue – Many older men receive unnecessary surgery or radiation exposing them to all the risks of treatment with little to no benefit.ZXZZZZZZZZZZZZZZZ
4. Doctors often do not discuss life expectancy – Patients should ask about longevity calculators before making treatment decisions.
5. Shared decision-making is important – Patients should be informed and ask questions before deciding on a treatment plan.
Final Thoughts
If you’re diagnosed with prostate cancer, don’t rush into treatment. Take time to learn about your options, discuss them with your doctor, and consider whether treatment is truly necessary. By making informed choices, you can avoid unnecessary risks and side effects while still managing your health effectively.