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More with early-stage prostate cancers choosing to wait and see before surgery

After Bob Garraty's annual PSA blood test led to the diagnosis of a tiny, slow-growing prostate tumor, he opted to do something almost as stressful as getting treatment.

After Bob Garraty's annual PSA blood test led to the diagnosis of a tiny, slow-growing prostate tumor, he opted to do something almost as stressful as getting treatment.

He postponed it.

Like a growing number of men, he chose "active surveillance" of his cancer. He had PSA blood tests plus physical exams every three months, and biopsies every year, in hopes that he would never need surgery or radiation - and never risk treatment-related urinary and sexual problems.

It didn't turn out quite that way. In October, after four years of surveillance, his biopsy revealed the cancer was turning more aggressive. To be safe, the 69-year-old workforce training consultant from the Harrisburg suburb of Hummelstown had prostate-removal surgery.

He has no regrets.

"I feel I did it the right way, waiting to see if I really needed treatment," he said recently.

This take-it-slow approach has been gaining acceptance.

From 2010 through 2013, 40 percent of men with early-stage prostate cancers chose surveillance - a rate three to six times greater than from 1990 through 2009, according to a national prostate cancer registry at the University of California, San Francisco. Called CaPSURE, it has collected data for two decades from 45 hospitals and community urology practices, including one in Lancaster.

Now, dozens of clinical trials are underway that seek to improve monitoring techniques and prevent progression of early cancers - using MRI scans, genomics, anti-hormonal drugs, even pomegranate extract pills.

Experts agree the surveillance surge is part of the fallout from the U.S. Preventive Services Task Force's 2012 recommendation against prostate-specific antigen (PSA) screening even for high-risk groups such as African Americans. The disavowal was a departure from the federal panel's 2008 advice to stop PSA testing at age 75, and a radical stance in the long debate over the value of screening.

The task force, which influences health insurance coverage, concluded early detection with the PSA test saves few lives, and unneeded treatment of cancers that might never cause problems leaves many men impotent, incontinent, or both.

That authoritative guidance has led to an abrupt decline in screening, and in diagnosis of early tumors. Studies of the dual trends were published last month in the Journal of the American Medical Association.

But the panel's guidance also has galvanized screening advocates, particularly the doctors who treat prostate cancer patients.

Advocates have lobbied for legislation to encourage screening; last month, Pennsylvania became at least the sixth state to enact such a law.

And as CaPSURE data suggest, advocates have been promoting active surveillance. Postponing therapy to see whether cancer progresses - a strategy once portrayed as nerve-racking and foolhardy - is now seen as a key to using the PSA test more strategically. Surveillance, which may include MRI scans and genomic analysis of tumor tissue, is more intensive than the traditional "watchful waiting," which was usually reserved for men near the end of their lifespans.

"Those who oppose routine PSA screening are correct in pointing out that overdiagnosis and overtreatment will still occur, even with increased utilization of active surveillance," Vanderbilt University urologic surgeon David Penson wrote in an opinion piece tied to the Journal of the American Medical Association studies. "However, patterns of care in prostate cancer treatment are clearly changing, potentially altering the harm-benefit equation for screening."

Matthew Cooperberg, a University of California, San Francisco urologic oncologist and a leader of CaPSURE, said, "We've been writing about overtreatment costs and banging the drum of active surveillance for decades. But we always said the solution is not to throw the baby out with the bath water, but to . . . focus screening on younger, healthier men" at risk of aggressive cancer.

Echoed Alexander Kutikov, a urologic oncologist at Fox Chase Cancer Center, "The challenge is to balance these competing goals of minimizing treatment for men with low-risk disease . . . while avoiding undertreatment for men with more aggressive cancers."

Evidence is mounting that PSA testing really has prevented deaths since it became routine in the early 1990s. Even Dartmouth Medical School physician H. Gilbert Welch, a prominent critic of overdiagnosis, published evidence in October: the incidence of metastatic prostate cancer diagnoses has decreased by half since 1988.

"Since the 1990s, we have driven down mortality rates by over 50 percent," Cooperberg said. "Based on the best mathematical models, one-third [of the decline] is due to screening, one third is better treatment, and the last third, we don't know."

Evidence is also growing that active surveillance is a sensible strategy. A definitive study - following treated men and monitored men to compare their survival - is still underway in the United Kingdom. But less-rigorous studies have found a very low rate of progression to metastatic disease or death with surveillance, about the same as with prompt treatment. Moreover, few patients quit surveillance by choice, and most did not require treatment within follow-up periods as long as 15 years.

Of course, being vigilant requires commitment from both doctor and patient. This month, a UCLA-led analysis of Medicare data found that of men on surveillance for less than five years through 2009, only 5 percent were monitored as closely as guidelines recommended.

That doesn't reflect Garraty's experience.

Although well aware of the screening debate, he always felt the PSA test provides knowledge, and knowledge is power.

"I started an annual PSA test when I was 50," he said. "I continue to believe in" screening.

In 2011, at age 65, his PSA level rose one point, to a mildly worrisome 5.9. His family doctor sent him to a urologist, who recommended a biopsy, which revealed cancer. Garraty's Gleason score - indicating how aggressive the tumor cells appear under a microscope - was 6 (the range is 2 to 10), making him a perfect candidate for active surveillance.

He gathered information about it - including by joining, which manages online support groups for patients - and examined his values and attitudes. He decided that avoiding or deferring possible treatment side effects was worth the psychological and physical burdens of monitoring.

"Every PSA test is like the Sword of Damocles over your head," he said. "And the biopsy isn't pleasant."

His wife was supportive, but to his surprise, two lifelong friends - fellow prostate cancer survivors - questioned his choice.

"When they were diagnosed, they both took the view: 'I want this cancer the hell out of my body, end of story,' " Garraty said. "They each called me and, in a loving way, said, 'Bob, you're taking a risk you don't need to take,' and, 'Treatment isn't always that bad.' "

Garraty is still recovering from his surgery, but he is happy to say his friends were partly right.

"So far, I'm doing great," he said.