Perspective

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

By James Eastham, MD and Vincent Laudone, MD
Wednesday, August 14, 2013
Pictured: Vincent Laudone  & James Eastham Prostate cancer surgeons Vincent Laudone and James Eastham

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.

James A. Eastham is a prostate cancer surgeon specializing in nerve-sparing radical prostatectomy and Chief of Memorial Sloan Kettering’s Urology Service. Vincent P. Laudone is a urologic surgeon specializing in robotic surgery.

Comments

Sometimes "do something" is apppropriate but the elderly male with prostate cancer may have a serious heart condition as well. Are there cardiologists on your staff to participate in the decision making?

Maurice, Memorial Sloan-Kettering has a Cardiology Service with nine full-time cardiologists who consult continuously with the other members of a patient’s treatment team to manage patients at risk for or who have existing heart disease. The cardiologists assist with medical decisions to ensure patients with both cancer and heart disease receive therapy safely. For more information on the Service, go to
http://www.mskcc.org/cancer-care/doctor/richard-steingart
If you would like to make an appointment with a Memorial Sloan-Kettering physician, please call our Physician Referral Service at 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment.
Thank you for your comment.

I am delighted and actually amazed that SKeven mentions the option of doing nothing. My late wife died of esopheagal cancer and she opted to forgoe treatment, thanks to the support of her GP and our daughter-in-law who both explained the downsides of agressive treatment. The oncologist was not happy, but she was well enough to recive visitors at home the Tuesday before she died, and enjoyed the visits of our three children, and phone calls. It was the right c hoice.

Cordially,

John Stoffel

John, we are sorry for your loss. Thank you for your comment.

I am 76 and was diagnosed with H.H. about one year ago. I have very bad vein so I can't have phleps. Tried Exjade it made my liver enzemes elevate. I also have NHL but don't seem to have any effect from it yet. In 2006 I had Retuxin therepy which my present onc said I did not need at that time. Any info you could give me would be greatly appreciated. Thank you, Patty

Patty, we are not able to answer personal medical questions on our blog. If you'd like to make an appointment to speak with a Memorial Sloan-Kettering doctor you can call 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

Yes, I agree 100% with Dr. Eastham. I have complete faith in him and his professional staff. Dr. Eastham treats me as well.

This fall I was diagnosed with a rare and aggressive cancer. The surgeons said that I could have 10 years if I had my nose, eye, flesh and bone removed. Part of that would be a year spent waiting for a prosthetic face. This is what the ACS recommends. I had radiation, and seem 2B in remission. Right now I can laugh, smile, eat chili burgers. I can be with my family and friends. This stuff is known to come back with a vengeance, but there is always the possibility that I'll die from something else. I just know that today I'm not dying from cancer. Tomorrow never comes. I ran into a man that went the ACS route-same stage-he had only 4 years-one year of that was spent waiting for prosthetics. I know there are many variables- I probably had a smaller field. Sloan-Kettering's site here helped me to quickly thrash through the smoke and fog of cancer care by providing a matter of fact library where I was able to read and make up my mind. I will say the surgeons and plastic nose makers were enraged. The author put it accurately-"Our fee-for-services-based healthcare system rewards intervention." It doesn't reward a patient's desire for quality of life, it doesn't foster respect for the patient and family's wishes. I have a pretty good team now. I'm so grateful that I'm not thousands of miles away listening to news, with part of my upper teeth cut out. I can smile today. I should be able to smile for quite some time.

This write-up sounds as if physicians are 100% positive as to when someone has low risk prostate cancer. However, from personal experience I found this is not the case at all. Biopsy results are subject to a large degree of inaccuracy. During my own experience, I was told we were dealing with low grade cancer. However, we made the decision to have surgery and post surgical biopsy of the prostate revealed a different story - the probability of metastatic cancer - which in fact had occurred. Upon researching the subject, I found that 40% of post surgical biopsy results are significantly different vs. pre-surgical prostate biopsy. So there is no one fits all solution here. Nobody seems to raise these kinds of statistics putting the patient equally at risk of making a bad decision. I'm not saying to disregard active surveillance but understand there is a risk there too. And its not a trivial risk. And by the way, this is not specific to prostate cancer. We had the same experience with my wife for breast cancer. She experienced several bouts of DCIS and we went with the recommended active surveillance. Guess what - we learned that cancer is unpredictable and there was not this linear path from no cancer to tiny detectable cancer to full blown invasive tumor. She was very closely monitored and still ended up with an invasive tumor. Lesson for me - be cautious - cancer is nothing to play games with. Assess the risk and trade-offs for you personally.

I am glad of this article. It seems to be a step in the right direction. However, I am puzzled about why conventional oncology never seems to ask this crucial question: "What made this person's body a place where cancer can thrive and what must we do so that is no longer the case?" Time and time again I have seen various treatments used to try and get rid of the cancer. As long as those treatments don't do horrendous damage and destroy the quality of life, I guess that is all well and good. However, quite frequently the cancer recurs. I am convinced that if the questions I cited at the beginning of this comment were raised in these cases, and then acted upon, the rate of recurrence was drop dramatically. I always ask those questions and I can't figure out why conventional oncologists almost never do. It makes no sense to me.

I have had prostate cancer for the past 15 years. I have done cryosurgery 2 x and IPT 2 x as well as hyperthermia (in Germany 2x in past 6 months) I also try to eat all organically if possible. If I had to do it again -I would do the German treatments (hyperthermia) I would not have had the 4 prostate biopsies that were done as well. Look at ALL your options. American treatments/doctors generally can not(FDA/BIG Pharma 's influence , graft) or will not look "outside the box" and many are ignorant about other treatments that are used all over the world.

I had the pleasure of meeting with Dr Laudone in April 2013, and I quickly confirmed he would be my surgeon, once I made my decision to proceed. I also spoke with Dr Polkinghorn (MSK Radiology). Both Dr's are obviously amongst the best in the world as well as the most approachable.

My PSA in April 2013 was 4.4 and the Gleason score of 6 (3+3). I decided to follow some of my own internet research and after each 3 months, check PSA and if a higher score - schedule surgery and if a lower PSA, go another 3 months. My June 28 score was 3.2, so went another 3 months. Sept 20 results: 1.64 . I'll continue with a Dec PSA and biopsy in April 2014. I'm doing 4 things: ketogenic diet, pomegranate extract, tomatoes/lycopene, and broad vitamin, antioxidant, and immune boosting supplement regiment. I also lost almost 15 lbs and back to college weight. With ketogenic diet, I found, you need to raise your caloric intake, not to lose more weight than wanted.

My Los Gatos, CA Dr (Stanford MD; 25 years exp) says he's never seen such a PSA decrease.. and while "wishful thinking" that cancer has gone away, but, that I seem a good candidate for doing nothing (else) for now.

Craig Luhrmann

What is Sloan Kettering's protocol for someone to be able to be on Active Surveillance?

Thank you for your question, R B. Dr. Laudone let us know that Memorial Sloan Kettering's protocol for selecting and then following patients on active surveillance is continually becoming more sophisticated, and this allows our doctors to individualize the follow-up regime for each patient. The advancement is partly a result of the information our researchers gain from analyzing patients who have been on active surveillance and partly due to the development of new technology that makes it possible to diagnose and follow patients more accurately.

re Raymond Black's Sep/2013 comment above ...
Doctors do not rely only on initial biopsy results to decide whether a patient should on active surveillance. Dr. Laudone said "... the most important factor in achieving a successful outcome for patients on active surveillance is to be certain from the very beginning that their cancer is appropriate for this approach. For this reason we now routinely do a prostate MRI at the time of initial diagnosis, and, if indicated, a second or “confirmatory” biopsy."

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