A 71-Year-Old Man With Urinary Problems

Gerald W. Chodak, MD

Disclosures

March 14, 2017

Many online prostate risk calculators can be used to determine risk for prostate cancer on the basis of patient race, age, family history, PSA level, DRE, and previous biopsy status. These are convenient when speaking with and counseling patients.

The management of localized prostate cancer has undergone considerable modification over the past 10 years. Before then, few doctors ever discussed conservative therapy with their patients. Generally, surgeons would recommend surgery, and radiation therapists would advise brachytherapy or external radiation. In recent years, that attitude has changed. Now, many patients with low-risk cancer (PSA < 10 ng/mL, Gleason score 3+3, stage T1C or T2A) do not need immediate treatment.[3] The reason is because the vast majority of those tumors will never cause harm.

Treating these men exposes them to the risk for various side effects, with little or no chance of extending their life. Key questions patients should ask to help them decide on a therapy include the following:

  • What are the odds I will live longer with this treatment?

  • What are the odds that cancer will recur?

  • What are the odds of developing each of the major side effects?

The problem with active surveillance for many of these men is the psychological burden of knowing they have cancer. Also, too often they are not being provided the information in a way in which they can process it. Hence, too many men with low-risk cancer are getting immediate local therapy. Genetic testing may make this decision easier in the future.

For now, all of the treatment options can be considered, with several important caveats. First, neither cryosurgery nor high-intensity focused ultrasonography has long-term survival data. For that reason, no one can determine the relative results compared with surgery or radiation; patients should be made aware of these shortcomings.

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