When “Do No Harm” Means “Do Nothing”

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.


Commenting is disabled for this blog post.

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
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.


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

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."

When one has had radiation poisioning and has to do it again,what are the consequences if any?

Ellla, we are not able to answer personal medical questions on our blog. If you’d like more information on this, we recommend you reach out to the National Institutes of Health’s Cancer Information Service at 800-4CANCER. Thank you for your comment.

How common is it for an 80 year old female to have a second triple negative invasive ductal breast cancer. Are there suggested studies that would include such a patient.

Ellla, a second breast cancer may have metastasized (spread) from the first breast cancer or it may be unrelated to the first cancer. If you’d like to speak to one of our doctors about this, you can call 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information on making an appointment. Thank you for your comment.

In the Craig's posting of Friday, October 4, 2013 - 6:45 PM, he mentions use of a Ketogenic diet. With the research happening at Boston College and University of South Florida (among other institutions as evidenced in publications seen in PubMed, NIH) I was a little surprised at the absence of an acknowledgement (pro, con, TBD) and any MSKCC professional articles on the web site. My personal interest is the efficacy of the diet as a means of control, less chemo for the same or better results for improved quality of life (fewer side effects). John's Hopkins is using this treatment for Pediatric Epilepsy and a study that showed positive results when applied to colorectal cancer patients. Is MSK involved in this research, who, and how can I get my wife's MSK Oncologist looped into a conversation to see if it's right for her. I am very interested in MSKCC's honest and objective opinion on this area of research.

Dear D. Kanellos, we sent your inquiry to Dr. Moshe Shike, an MSK gastroenterologist, internist, and nutritionist with a particular interest in cancer prevention, including the roles that screening and nutrition play in the prevention and development of cancer. He said that there is not enough evidence to show that the ketogenic diet helps to prevent, control, or treat cancer. We encourage you to circle back with your wife’s oncologist if you have additional questions regarding what sort of diet or nutrition plan is best for your wife’s particular circumstances. Thank you for reaching out to us.

Based on PSA level of 6.2, MRI 3D with / without contrast showing a tumor contained in the prostate. A urine test for PCA3 showing negative.
What is more important to determine a need for biopsy ? the high psa + the mri or the urine test. This is a general question.

Dear Marcos, thank you for reaching out to us. We sent your inquiry to Drs. Eastham and Laudone, and they responded:

Dr. Eastham: “I rely more on the MRI findings. If the MRI is completely normal the likelihood that a prostate biopsy will show a significant cancer is low. If the MRI does show a lesion this gives us more confidence is recommending a biopsy but also gives a target to biopsy.”

Dr. Laudone: “Agree. There is no one test that will predict the results of a biopsy and therefore there is no test that can replace a biopsy. Prostate MRIs continue to improve and now they are probably the best indicator of what a biopsy is likely to show in a man with an elevated PSA.”

We hope this is helpful.

Excellent service. Very informative

I just want to warmly congratulate the drs for this article. I have a prostate cancer diagnosed in 2010, intermediate stage (T2B, GL 3 + 4) and I refused to treat it despite enormous pressure urologists. In my country (France), the vast majority of them want immediate treatment, regardless of patient really notice, even if aged (> 70 years) and with cancer "light". A scandal.
Again my best congrats.

My father was Diagnosis with Prostate Cancer recently because of his health risk he decided not to do anything( No Biopsy) He has a blockage in the main artery in the neck(Can not stop blood thinner for 5-7 days in order to have a biopsy procedure),High Blood Pressure,Diabetes and Heart Disease and he will be Eighty in Oct. I can't sit around and do nothing so I found a non surgical procedure it not a cure but it will slow the cancer down and Increase survival while maximizing quality of life. That all he was asking for he just has to take a pill or a shot This is the Hormone Treatment. I read this can help stop the male hormone testosterone and delay the progression of the cancer. What do you think about this kind of treatment.
Your's truly

Lisa, because every case is different, we are not able to answer individual medical questions on our blog. We recommend you discuss this with a medical professional who is familiar with the case. If your father would like to have a consultation at MSK, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment.

We live in Indonesia, my father 5years ago diagnosis of prostate cancer,and because he tried to herbal first(sour soup leaves) he raised his psa quickly and become metastatic in several months only, he already had prosterectomy, and at that time the level of radical prostate is 4+5 that is gleason 9, he also taking hormon injection every 3months and i forgot the name, because after surgical treatment the psa begin to increase, and after that since psa level increase again the doctor in singapore give him another additional pill and it works, since now he had psa increase again the doctor in singapore give him another medicine but he was not suitable and he change it with rwtiga if i'm not mistaken, what should we do and how much its cost if we going to consult here and where is the address.. Is it can be cure now? Or just survive

This information is so valuable , if only the average non medicle person could understand it easily and quickly and believe it.
October 2013 a check up eventually wrecked our very comfortable family. It was around three years since I had even been to a doctor , my wife asked me to go for a check up at 60 years of age.

"You have an elevated psa" , come back to see me. It was 10 , two weeks later a new test placed it under 4 , with no treatment.
Our family gp did the dre and said no problem there , probably an infection , we must monitor this closely , every six weeks , if this psa number moves and girates around we will investigate further.
For 10 consequtive months it followed under 4.
12 months later October 14 I had to visit another doctor , (I couldn't get into our family gp) , for a medicle certificate due to two days off from work , I figured it was just the flu , but he ordered blood tests.
When the blood test came back he saw the previous "elevated psa" and directed me to see a urologist.
When I saw that urologist I explained to him my family gp advised we just monitor this at the moment.
"I don't take any notice of what the gp's think" he said , "I move straight to a biopsy , THIS ELEVATED PSA IS DANGEROUS" ( emphasis added).
So 10 day's later the biopsy came back at a 3+4=7 psa 3.7.
His recomendation , " you move immediately to a surgery , radicle prostatectomy with this other recomended surgeon , I have organised a consultation for you.
You have prosate cancer , it's agressive and active , you need to move quickly".
My wife broke down into tears and was inconsolable for 2 day's after that.
I said to him "are you sure about this , could there be any mistake , I have absolutely no problems or symptoms, this has all come from a chance check up a year ago" ?
He said " look I wouldn't dilly dally with this it's already been a year , I have seen plenty of men waste time with this and in no time they are back wanting to know how I can help them , but by then it's too late I can't help them ".
The surgeon who did the radicle is internationally recognised and strutts the stage of international prostate cancer conferences telling and boasting of his proud record , he did pretty much zero to stop the freight train speed that had been alloted my situation , we were scared to death and couldn't understand it all , we both working long hours so couldnt try to become medical urologists.
The removed prostate came back from pathology at 3+3=6.
Now our lives are in ruin , more because the whole procedure should NEVER HAVE HAPPENED than anything.
Now we understand what should have happened.
#Should have had been a secound opinion on the biopsy pathology.
# Should have been monitored and followed for change.
#To finish this internationally recognised surgeon of some distinguished fame had only just changed over from open surgery of some 2,000 procedures to Robot assisted da vinci procedures , where the learning curve is some 700 to 1,000 procedures , I was among the first , so the the results are poor.

Dear Terry, we are sorry to hear you’ve been through all this. Thank you for sharing your story, and best wishes to you.

How much faith should one put in the Polaris test. I had a biopsy in 2014 and the tumor was examined using the Polaris genetic test. Results came back stating "the risk of losing your life to prostate cancer over the next 10 years is about 2%". I have been having psa test every 4 to 6 months and they have been 10. Gleason score on two biopsies have been 6. I have a pacemaker/defibrillator and have been fairly active. I am 77. I really do not want to do anything in the way of treatment. What do you think?

I will be having a conference with your physicians just as soon as I get my materials faxed off to you. I feel very fortunate to have found this site. As an aside many years ago my family had a small store in Harrison, New York and one of your physicians came in every day for coffee, a buttered roll and a copy of the New York Times. He was on his way to your facility in West Harrison. His name was Dr. Sigouria (I am using phonetic spelling on his name).

Dear David, best wishes for your upcoming appointment.

How does one determine that a prostate cancer will be metastatic? Can that be determined from the biopsy samples?

Dear Jerry, with prostate biopsies, pathologists evaluate cancer grade and tumor quantity, which may help determine the likelihood of tumor aggressiveness and an appropriate management/therapeutic strategy.

Thank you for your comment.

Your blog referred to 'doing nothing' for patients at low risk. Could you please comment, in general, for patients at higher risk? Thank you.

Dear Tim, in general if someone’s cancer is higher risk they would likely want to consider intervention sooner, although there are other factors involved such as the person’s age overall health. This is something that should be discussed in consultation with an expert. Thank you for your comment.