Hopkins Voices

Prostate Cancer: Active Surveillance or Immediate Action?

An insightful interview with Urologist and Surgeon Arthur Burnett.  Dr. Burnett discusses the seemingly contradictory studies that advocate 'active surveilance' versus studies that seem to advocate immediate action.

Burnett is a surgeon and urologist in the Johns Hopkins Brady Urological Institute.  The Brady Urological Insitute has consistently been ranked the top Urology program in the United States by U.S. News & World Report for the past 15 years.

Arthur Burnett, M.D., is very emphatic when he says that “prostate cancer does kill men, but that there might be other, less aggressive, treatment options”, which brings a dilemma to urologists and patients. Dr. Burnett makes an update on prostate cancer and clarifies some myths involving the second cause of cancer-related deaths in the United States.

Question: What is the picture of prostate cancer today?

Dr. Burnett: Prostate cancer is a very prevalent disease in the United States and also worldwide. Here in the United States it is recognized as the leading type of cancer among men, and for cancer-related deaths it only loses to lung cancer.

Question: Have any causes been determined?

Dr. Burnett: There are many possible causes related to prostate cancer. They may be related to diet, to lack of activity or exercise and maybe even genetic relationships. Because it happens more in more industrialized countries, it may also have a relation with exposure to chemicals or pollution and processed products. We are now definitely looking at the so called “bad habits” when it comes to how cancer in general is developed. That might be the reason why prostate cancer is prevalent in the United States, for instance.

Question: Can men prevent prostate cancer?

Dr. Burnett: This is a very loaded question, but to start, I would like to say that one has to be aware of the prostate cancer statistics, and they are not small numbers. Today, it is estimated that 1 in 8 men may be at risk to develop prostate cancer in the United States. I believe that is not an unrealistic prediction for other parts of the world, as well. There’s certainly a great potential if there’s family history, so if you have a history of a father, uncle or brother with prostate cancer and if there are multiple family members with prostate cancer, then the risk is higher.

However, this disease is also very prevalent on a non-genetic basis, what we call sporadic prostate cancer, and this may be related to the other possible factors we talked about [poor diet, lack of exercise, exposure to pollution and processed products]. Although some of our “bad habits” can be modified with definite benefits other than reducing the risk of prostate cancer, this remains an area of intense investigation. Should men change drastically change their diet and habits? Should they never eat red meats again?

That sort of thing remains very unclear and, conceivably, a better course of living that includes a balanced diet and appropriate activity may have benefits not only to your cardiovascular health, but maybe for other things, including the reduction of your risk for prostate cancer.

Question: What kind of tests are the most important? Are there any advances in that area?

Dr. Burnett: The most important test is still the PSA test, along with rectal examination of the prostate. They are very simple and basic screening tests, and should there be a question in diagnosing, a biopsy of the prostate follows. That requires a pathological review and if cancer is found, additional tests will be done to determine whether the disease is in its early stages or late stages. That’ll dictate what kind of treatment plan is the best.

There are new biological markers and blood tests being investigated to detect prostate cancer better, but none at this point of time is superior to standard PSA. There are different kinds of the PSA test being investigated too, but none have been approved by the regulatory agencies as a standard test that should be done.

Question: Some physicians say that many tests and biopsies turn out to be unnecessary in diagnosing prostate cancer. How does one choose the best treatment?

Dr. Burnett: You are making a remark here that some men may be “overtreated” for prostate cancer, and we are really facing a dilemma more and more these days on how to properly diagnose and treat this disease. There’s no kidding when we say that prostate cancer does kill men, but in some cases it might be so minimum that there is the opportunity to consider following it closely with an active surveillance program rather than doing any sort of intervention.

Prostate cancer is not always uniform. It is a broad spectrum disease that consists of both low profile and high profile presentations and it is a matter for us urologists to work through some of the diagnostics and the health style of the patients. There are other variables that allow us to decide whether the patient should move forward and do the procedure or stay with the active surveillance program.

In my mind, it is appropriate that the patient is treated properly, and he does not have to have one specific treatment. The real issue is that the interventions for prostate cancer are not always simple and without some risk. Indeed, there are risks for radical and partial prostatectomy. For radiation therapy, there is a potential risk. For more advanced disease, that may involve hormone suppression treatment, there is also a risk. So, to balance, we have to figure out for a certain kind of cancer that may progress slower, faster or not progress at all whether the treatment will be more harmful than the cancer. That is the dilemma we face. The solution I see is to always consult with a real specialist in this area to sort things out and make the best for each presentation of the disease.

Question: How do patients react when you decide not to treat them for a diagnosed cancer or to treat something that they even feel?

Dr. Burnett: Patients’ reactions to the diagnosis of prostate cancer are varied. It is definitely a challenge for a man that feels perfectly well to understand how they came up with prostate cancer and why go ahead with some sort of intervention when they feel fine.

On the other hand, some men that have a diagnosis of prostate cancer push for immediate intervention when that might not be the best option. Sometimes it takes a real effort to convince a man that active surveillance is enough. Again, the best treatment will be decided between each doctor and his patient, considering all risks.