On Cancer: When “Do No Harm” Means “Do Nothing”

Advertisements for prostate cancer therapies are everywhere. Patients are offered a bewildering array of treatment options: radiosurgery, cryosurgery, proton beam therapy, robots in the operating room.

The word “cancer” triggers a range of understandably negative emotions, which can result in a rush to treatment. But often, the most appropriate option for many men is never mentioned: Do nothing.

While prostate cancer is the second leading cause of male cancer mortality, accounting for approximately 29,000 deaths annually in the United States, the overwhelming majority of men who receive the diagnosis will not die from their disease. Indeed, two recent large clinical trials in men with prostate cancer reported that those with low-risk cancers — about one-third of men diagnosed with the disease — had only a 3 percent risk of death from their cancer 12 years after diagnosis, regardless of whether they were treated or not.

Treatment of prostate cancer can be associated with significant risks. In addition to the general risks (and expense) of surgery and radiation therapy, men treated for prostate cancer may experience the unpleasant and sometimes debilitating side effects of urinary incontinence, rectal bleeding, and sexual dysfunction. Still, many physicians are inclined to recommend treatment for all men, even if the risk posed by the cancer is extremely low.

Our fee-for-services-based healthcare system rewards intervention. Substantial time and effort is required to counsel a newly diagnosed prostate cancer patient that deferring treatment may be the best approach for him. Simply scheduling an appointment to begin treatment can be done far more quickly and easily.

Even specialists at “centers of excellence” tend to tout the latest technological innovation — usually as part of the hospital’s branding campaign — to the exclusion of other, perhaps more suitable, options.

Active Surveillance

Contrary to the way it sounds, “doing nothing” is actually a dynamic, comprehensive program for managing low-risk prostate cancer. Also called active surveillance, it is a risk-based strategy that identifies men who will benefit from treatment while carefully monitoring those who likely will not.

Active surveillance involves following men who have been confirmed to have a low-risk cancer and periodically reassessing that risk. At Memorial Sloan-Kettering, we recommend prostate cancer treatment for these men only when their disease shows any signs of progression or changes in its characteristics, and only when they are healthy enough to benefit. In the near future, further advances in cancer genomics will allow an even more refined approach.

While no management strategy is perfect, a risk-based approach will result in far fewer men undergoing treatment that is unlikely to be of value. In a technology-driven healthcare environment that aggressively markets less invasive and less radical treatments, doing nothing may be the most radical and appropriate treatment of all.