Choosing Watchful Waiting

A couple was walking on the beach, taking in the ocean air and a beautiful cloudless day when they came upon a stretch of beach that was just littered with literally thousands of starfish that had washed up on the beach during a storm the night before. They couldn't believe how many were lying helplessly on the beach starting to dry out and die in the sun. As they walked, they ran into a little boy who was picking up starfish, one by one, and tossing them back into the ocean. They stopped and asked him what he was doing.

"Rescuing starfish." He replied.

"There are thousands of them," they said, "you can't possibly save them all. You’re not going to make any difference."

Undaunted, he picked up another starfish and tossed it into the ocean.

"I made a difference to that one." He said.
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So what's the lesson? Statistics are just statistics. The "law of large numbers" does not apply to a sample size of 1. Me.

good post on the subject, thanks for sharing that, glad to see that trend developing, i feel its the best option for those meeting a safe criteria for AS. Hope it continues to be used in the future.

  Dreamerboy said... At my prostate cancer support group, I sometimes feel like a Baptist at a Catholic church or vise-verse. Thats an insightful comment, Dreamerboy, and it highlights the ignorance and lack of knowledge/understanding of what AS is all about even among PC patients who you would think would be well educated and wish to offer meaningful advice to the "next (low risk) guy through the door."  This "cognitive dissonance" was described by Dr Bradley Hennenfent in this passage: We need to look at the RP's failure in low-risk men to extend life, tabulate its side effects, then show men this information and ask, "Are these disabling side effects okay for an operation that hasn't even extended survival in a controlled study with nearly 25-years of follow-up?" I am frequently amazed about how often it is the impotent man who screams the loudest in favor of the radical prostatectomy for fellow low-risk patients.   I think it is partly the Stockholm Syndrome and partly the inability to accept that a terrible sacrifice did not result in extended survival.   One doctor colleague calls the situation " cognitive dissonance ."     It is difficult to engage in conversations with low-risk men who have already had an RP because I don't want to hurt anyone's feelings.   A RP can't be undone.   The men that are post-RP, that geared up for their major surgery, and are gung ho—you can't tell them that they might have done the wrong thing, not after what it has cost them financially, emotionally, and physically.   THAT is why doctors, and the well-educated (school of hard knocks) patient support sites like HW and at your PC support group, need to communicate more effectively with new patients up front to overcome the emotional-driven  rush into an aggressive treatment.    While men are unwittingly rushed into a drastic operation without a full understanding of the consequences, they defend their surgeon (the one who did the rushing) with the notion that he "saved their lives," when in fact for low-risk patients the surgery probably had no impact on their longevity.

akai, that’s cool.   As Dr Snuffy Myers says, PC treatments are like a game of golf…ya gotta play it as it lies.   The decision to not rush into treatment doesn’t mean a lifelong decision to not get treated.   If things change, then you play it as it lies at that time.   There is a decent percentage of men who end up simply deferring treatment because their case eventually progresses, but a larger percentage of guys avoid the unnecessary aggressive treatment (and side effects of treatment). Hopefully you are aware of how the best run and most successful AS programs incorporate lifestyle changes to help stack the odds in your favor for the best possible outcome.   Studies have shown how men with low risk biopsy-confirmed PC (just like you) have on average dropped their PSAs (as a measure of PC progression) through a commitment to diet, exercise, and stress reduction.   Some men think lifestyle changes are too much to undertake…that seems short-sighted to me. Are you aware of the studies of pomegranate extract which have also slowed PC progression?  It is consistently recommended as a supplement by the leading PC clinicians for men seeking to slow PC progression; not as a 100% "cure" for prostate cancer, but as another arrow in the quiver to stack the odds in your favor. Best wishes…

Interesting article. After everything we've read in the last few years, I know my husband would have elected watchful waiting had he not been a Gleason 7. And sometimes I even wonder about that 7 part...would it really have progressed more quickly?

But this is what bothers me: the repeated biopsies. I felt relieved after both of my husband's prostate biopsies that he had escaped infection. Infections, whether hospital-acquired after surgery or community-acquired, are really serious and very scary. And today so many bacteria are becoming resistant to antibiotics, even today's more powerful meds. Does this give anyone else pause?

This article is based on the PIVOT study. Although AS is a proper way to deal with PCa, AS it being "forced" without one verified protocol and not fully supported by urologists at this point in time. Not that is not the best way to go for many men who can wait and monitor their cancers instead of acting out of fear. The data used to support AS in this article leaves much to be desired. Here is some data from the PIVOT trial:

I cannot see a great significance from this trial’s results for currently diagnosed men to make a treatment/no treatment decision. The fact that they could not get enough participants to provide the necessary statistical power cannot be ignored.
Out of 5000+ patients. only 731 were finally randomized throughout the years.

Patients were randomized at 44 Veterans Affairs sites and eight National Cancer Institute sites.

Primary entry criteria were: age < 75; clinically localized prostate cancer (T1-T2NxM0); PSA < 50 ng/mL; negative bone scan; life expectancy of at least 10 years. Among men with complete data, 40% had low-risk cancers, 34% intermediate risk, and 21% high risk.

As you can see older men (as old as 74)with PSA as high as 49 were treated surgically or just observed. Is this cohort of men typical of the current number of men diagnosed these days? Nevertheless the study is being used to shoe that surgery is not better than observation.

In spite of this, the study results show that overall mortality was 6.6% lower in the surgical series and disease-specific mortality was 31% lower in the surgical cohort. Maybe not statistically significant because of the small size of the study, but still an eye-opener given the results and conclusions expressed by the authors. They tell a different story even when they took years to publish their results.

Again, those of us surviving PCa need to support AS as a proper method to avoid over treatment, but should not be persuaded by those that are pushing unreliable science to do it.

RalphV

That median exact age of 67 means that 365 men were older than 67 when randomized. Is it common to treat men surgically with PSAs as high as 49 these days? Give me a break! On top of that less men over all and with prostate cancer died in the surgical cohort. How is that possible? Ah! Those darn statistics...

RalphV

I remember when I was first Dx. My Uro laid out all the options, AS wasn't one of them. He then asked if I wanted to meet with the surgeon within the group & I said yes. Before the meeting with the surgeon I found this wonderful website called Healingwell. There they talked about this new thing I had not yet heard of called Watchfull Waiting. So I discussed it with the surgeon & WE agreed it was the prudent thing to do. Thanks to all my Brothers & Sisters here for TALKING about IT. Whether you agree with it or not, don't take it away from me or any other man when it's time to make that big decision. And let's keep talking about it.

Are you aware of the studies of pomegranate extract which have also slowed PC progression? It is consistently recommended as a supplement by the leading PC clinicians for men seeking to slow PC progression; not as a 100% "cure" for prostate cancer, but as another arrow in the quiver to stack the odds in your favor.
 
Yes, I am aware of the claim, however, I want my first PSA after my Dx to be free of anything that may mask the true score.
I am also aware of the details on the PIVOT study. My Uro wants to do PSA every three months, Color Doppler UL with Elastrography every six months, perhaps with PCA3 test and DRE, then biopsy every two years. I am not quite comfortable with Bx every two years, but I have just been Bx in August, I have plenty of time to push this issue. Other program (UCLA etc.) requires a confirmation Bx at six months after the initial Bx, then about once a year to start.
So far, I have looked into surgery and Proton Therapy and not much else (seeds, IGRT, HIFU, Cryo). Somehow, I do not feel the same urge as when I was first Dx, I do not know if I am ignorant or stupid for not panicking. I think the Uros that I consulted with told me I have plenty of time to decide. I am enjoying the relief of the pressure and strees from being Dx with PCa, this may or may not last. We will see.