CASE 3: A 50-year-old man with an abnormal DRE (slightly indurated left lobe), a PSA level of 0.2 ng/mL with 1/12 positive cores (one percent) and Gleason 6 prostate cancer (from the practice of Richard Davi, MD)
| Tracks 1- 6 |
| Track 1 |
Case discussion: A 50-year-old
man with PSA at 0.2 ng/mL and
small volume disease |
| Track 2 |
Rationale for biopsy of patients
with a low PSA level |
| Track 3 |
Watchful waiting for patients with
a small volume disease |
|
| Track 4 |
Incidence and challenges of
nonsignificant prostate cancer |
| Track 5 |
Watchful waiting for patients with
low-risk disease |
| Track 6 |
Role of dietary modification and
vitamins for patients on watchful
waiting |
|
|
Tracks 1-6
DR MOUL: This patient has a very small volume of disease. Ninety to 95 percent of urologists would say he should undergo a radical prostatectomy. Laury Klotz, Bal Carter or even Peter Carroll would probably try to teach us that we should not look at him as age 50 but rather as a patient with extremely small-volume prostate cancer, and we should offer him watchful waiting. He would end up with a radical prostatectomy in my practice because he would be “freaking out” and wouldn’t tolerate a watch-and-wait approach.
DR LOVE: Dr Davi, was it your assessment that this patient could have tolerated
a watch-and-wait approach emotionally?
DR DAVI: I didn’t think so, especially with his wife crying and saying, “Let’s do something.” I leaned strongly toward the radical prostatectomy.
DR LOVE: Dan, what would you have suggested?
DR PETRYLAK: I believe you can offer him all modalities, including watchful waiting, but the practicality of this patient undergoing watchful waiting is low based on what you’re saying about his family situation.
DR NIEDER: I used to think watchful waiting was for 75-year-old men with lots of comorbidities, who were likely going to die from some other disease manifestation.
When I think about a 50-year-old healthy guy with very low-volume disease and favorable parameters, I believe it would be reasonable to rebiopsy him in a year. If he had truly very low-volume, low-grade disease, maybe the abnormal DRE was driven by prostatitis or some other factor besides a bulky tumor. If the volume and the Gleason score were still the same, it wouldn’t be unreasonable
to keep following him like that.
He still has cancer, but it’s clearly not life-threatening cancer. You might be able to hold off on a prostatectomy or radiotherapy for five years or so.
DR MOUL: The problem is that we’ve opened Pandora’s box. The patient and family are extremely concerned about the “C” word. We know from Wael Sakr’s study (Sakr 1993, 1996) that at 50, a man has a 30 to 35 percent chance of having autopsy prostate cancer, yet most of those men never die of prostate cancer.
From an academic standpoint, you may have found autopsy prostate cancer, but from a practical standpoint, you’re dealing with a guy who knows he has cancer.
DR TRIPP: I have a completely different take on this, and I have a similar patient in my practice. We’re watching him, and he’s highly anxious. We had the exact same conversation on autopsy cancers — studies show that 30 percent of patients at the age of 50 have cancer, but is that the same cancer that we’re discussing?
I don’t know if I agree that this gentleman has cancer. Obviously, he has several glands that have cancer, but what is the significance of it? I did exactly what Dr Nieder suggested. I waited a year and did another 12 biopsies, which were completely normal. So I have 23.9 biopsies out of 24 that are completely benign. We’ll probably take another biopsy in the next year or two — his PSA has been stable — to see exactly where we are and whether he has cancer.
DR LOVE: I was intrigued by the follow-up with this patient and what actually happened with him.
DR DAVI: His sexual functioning was important to him, because he was only 50 years old. After I provided him with all of the treatment options, I suggested that he see a very well-known urologist in Maryland to get a second opinion.
The urologist wasn’t certain that this was, in fact, cancer, so he had his pathologist
confirm the diagnosis. He recommended the patient have a PSA and rectal examination every six months and a biopsy every year. At that point, he seemed comfortable with that strategy, and I was also.
DR LOVE: Judd, any closing comments?
DR MOUL: Bal Carter has the prospective watchful waiting study at Johns Hopkins, and I don’t know if that’s the particular urologist he saw, but it’s a great academic study for patients like this man. The most significant issue is the psychological well-being of the patient. Can he and his family accept this active surveillance approach?
We did several studies evaluating the outcome of watchful waiting when I was in the military. The dropout rate for men under age 70 was almost 75 percent at five years. So, if that study holds, this man would probably have about a 25 percent chance of being maintained on active surveillance five years from now. On the other hand, if they educated him and counseled him properly, perhaps his chance of dropping out would be less.
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