When "Do No Harm" Means "Do Nothing": Managing Risks

Pictured: Vincent Laudone and James Eastham

Prostate cancer surgeons Vincent Laudone and James Eastham

We are pleased that our August 14 post about active surveillance of low-risk prostate cancer generated such a meaningful discussion about the options available for dealing with the disease. Thanks to everyone who commented!

Many of the comments have appropriately focused on the concept of risk, which is highly relevant for the discussion. Virtually every decision we make as surgeons or patients involves some type and degree of risk. Treatment involves risks, no treatment involves risks. We cannot avoid or eliminate that risk. What we can try to do is to minimize it.

Active surveillance is a risk-based strategy that identifies men who will benefit from prostate cancer treatment while carefully monitoring those who likely will not. Before we recommend it to a patient, we try to understand his cancer to the full extent current technology allows.

This usually means obtaining various imaging studies such as a prostate MRI as well as performing a repeat biopsy to be sure we have not overlooked a more significant cancer. Genomic testing of the biopsy specimen has recently been developed and can aid in determining the aggressiveness of a given prostate cancer.

Once someone is placed on active surveillance the work does not end there. Careful monitoring with frequent examinations and testing is mandatory.

None of this can eliminate all risk or guarantee a perfect outcome, but it can be part of a successful strategy that balances a variety of factors and concerns that are unique to each patient.

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.


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Mass Gen.'s study-fatality risk SAME for prostate treatments: rad,surgery or act. Surveilance-True or False?
Please verify this study & and how I can get a copy!

Hi, Bob, we sent an email about this to the address that you provided. Thank you for your comment.

What tests do we have for someone with high PSA's, but doesn't want a biopsy done?
If you open up cancerous tissue by a cut or nic it with an instrument, can it spread to other tissues in the body?

Bob, if you’d like to learn more about how Memorial Sloan-Kettering diagnoses prostate cancer, you can visit this page on our website: http://www.mskcc.org/cancer-care/adult/prostate/screening-and-diagnosis. If you have specific questions about how prostate cancer is diagnosed, we recommend you call the National Cancer Institute’s Cancer Information Service at 800-4CANCER. Thank you for your comment.

My husband was following the active surveillance route and the plan has now changed based on a recent MRI and biopsy result. How closely do your physicians rely on the nomogram posted on your website? We are waivering between prostatectomy and brachytherapy as the outcome data appears to be very similar.

Deb, thank you for reaching out. We passed your question on to MSK prostate cancer surgeon Behfar Ehdaie, who responds “The nomograms are not best used to distinguish between treatment choices because the men whose data were used to make the predictions for brachytherapy and surgery are different. Instead, the nomograms should be used to provide general information regarding prognosis of the specific patient (regardless of treatment type) and guide follow-up.”

I had cyber knife radiation in January 2011. My PSA dropped to .5 until eighteen months ago. I am 84 and have issues walking, lost a kidney to cancer, half a thyroid, and several other non-cancer specific surgeries. My PSA is now 55.
I have had non-neuclear Bone Scans and MRI's.
I have been offered Lupron treatments and have avoided them because the side of the effects.

I have been told that HIFU is not an option as there needs to be a "clear target." My doctor has agreed to "watchful waiting," but the was before my PSA elevated from45 to 57 in two and a hLf months.
Are there any options that have such debilitating side effects. At 84, and without a specific area to focus on, I am hesitant to reduce the margin quality of life I now possess.