Watchful Waiting

Watchful waiting is an approach in which the patient does nothing outside of regular monitoring, and waits for something to occur. The merit of long term “watchful waiting” is questionable as there is a lack of data to support this approach.

To the contrary, expectant surveillance is an option for some early stage prostate cancer patients who want to continue to monitor their PSA, do more research into treatment options, or postpone treatment because of work or family schedules. The exceptions are those patients regardless of age who have a life expectancy less than ten years because of some other significant medical condition, such as severe heart disease or another form of cancer that is likely to be a cause of death before prostate cancer. Recent studies, however, reveal that even an 80 year old man has a ten year life expectancy. These men may be advised to simply monitor the progression of the cancer with periodic laboratory tests and physical examination.

Advocates of watchful waiting often correctly point out that the term is misleading and should not imply passive waiting or doing nothing. A more active program of surveillance is intended and may include a diet and fitness regimen undertaken in consultation with a doctor and tailored to the patient’s condition. The process of waiting to see if the cancer progresses is bound to cause prolonged periods of anxiety for many men; and therefore, a strong sense of commitment and mental stamina are demanded of those who choose to wait rather than be treated.

Early proponents of watchful waiting based their argument on Swedish data, which received a great deal of publicity back in the early 1990s. The Swedish researchers argued that there was no survival benefit for patients treated versus patients who were not treated. But if we look closely at those studies, it turns out that the patients were not just undergoing watchful waiting, because when the disease started to progress in men who had not been treated, they were subjected to endocrine therapies such as hormonal therapy or orchiectomy (castration). Therefore, the Swedish data did not provide an accurate picture of watchful waiting.

With regard to the Swedish data, it should be noted that orchiectomy or medical castration, continuous “hormonal therapy” or “Androgen Deprevation Therapy” may in itself lead to increased risk for diabetes, high cholesterol, hypertension (HTN), and arteriosclerotic heart disease (ASHD), thus increasing the risk of stroke (cerebrovascular accident-CVA) and heart attack (myocardial infarction-MI). When all is said and done, patients in this Swedish study were found to have died from causes other than prostate cancer, when in fact, it was the treatment of their prostate cancer with endocrine therapies that caused the early deaths.

It is important to consider, as well, that men undergoing such endocrine/hormonal therapy treatment will most likely lose their sexual function during type of treatment. Therefore, taking this course of action and thinking it will preserve sexual function is not a prudent, well-informed decision, especially given the existence of prostate cancer treatment options that are effective in preserving sexual function. It should also be noted that more recent research from Case Western University School of Medicine in Cleveland reported in November 2007 demonstrated that patients with localized prostate cancer cut their risk of dying of the disease in half when they have brachytherapy in conjunction with external radiation therapy compared to those men who do not get active treatment (watchful waiting) within six months of being diagnosed. Other research published in JAMA (Journal of the American Medical Association) based upon the Medicare SEER (Surveillance, Epidemiology and End-Results) data, also demonstrates greater survival with brachytherapy treatment versus watchful waiting.