The Death of “Watchful Waiting”

You have probably heard the old saying, “Cancer isn’t one disease…it’s hundreds of diseases.” All true.  All very different. And prostate cancer certainly is. About one in eight men will have prostate cancer at some point in their lives, with an average age at diagnosis of 66. There’s another old saying. “Men are likely to die with prostate cancer, but not of it.”  Well, that’s not exactly true. Prostate cancer is second only to lung cancer in causing death in men. Nonetheless, because of a carefully developed risk assessment system based on Gleason score at biopsy, guidelines have long recommended “watchful waiting” as the most appropriate treatment for low-risk cancers. Think about it. How many other cancers have guidelines that begin with “Don’t treat?”

But check this out. What you will see is that the NCCN has now changed its guidelines for managing low-risk cases to give equal weight to watchful waiting, radiation, and surgery. This shift in guidelines is interesting in and of itself, because it is unclear why it is being made and why now. Even more fascinating is the reaction of prostate cancer experts, the most vociferous of whom are seeing this as a return to the draconian days of the past AND as providing license for widespread, often unnecessary, surgery and courses of radiation therapy. The impact of such interventions on quality of life, e.g., surgery frequently resulting in impotence, is one of the reasons that watchful waiting seemed like such a good idea in the first place.

Bottom Line. Sort of an interesting discussion, actually. What you see reflected in the comments in this piece are two extremes. More conservative doctors are upset that this change in guidelines will make it more difficult for them to convince men to rely on watchful waiting. At the other extreme, there is a concern that this guideline shift will permit money-motivated practitioners to greatly enhance the profitability of their practices by pushing patients toward getting interventions they may not need. The result of all of this? Something tells me that we have not heard the last word on this one! 

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