Watchful Waiting Is Safe for Prostate Cancer

If your doctor gives you a prostate cancer diagnosis, it’s okay to wait before having surgery or radiation. Here’s what you should know about watchful waiting.

After adjusting for changes in the age of the population, the rate of U.S. prostate cancer cases fell dramatically in the early part of the century, but rates have increased since 2014, with a slight drop in 2020. The 3 to 5 percent increase per year is concerning. It’s also bad news that late-stage diagnoses are growing fastest of all.

The increase will likely lead to more prostate cancer deaths over time, according to Jeff Michalski, MD, president of the American Society for Radiation Oncology and a professor at Washington University School of Medicine in St. Louis, Mo.

“The increasing percentage of men presenting with advanced prostate cancer, which is much more difficult to treat and often incurable, is highly discouraging,” said  Karen E. Knudsen, PhD, chief executive officer at the American Cancer Society.

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The changing rates do not necessarily mean that you should be screened for prostate cancer. But you should talk to your doctor. Michalski suggests that the new data should signal the U.S. Preventive Services Task Force (USPSTF) to update their screening recommendations.

Most men diagnosed with prostate cancer do not die from it. More than three million American men who have received a diagnosis are alive today. Earlier detection and advances in treatment lowered the death rate by about half, from 1993 to 2013. Often, a slow-growing cancer doesn’t even require treatment.

The main method of catching cases early has been a blood test for high levels of prostate-specific antigen (PSA). Doctors, scientists, and public health experts have warned for years, however, that PSA screening for prostate cancer does more harm than good. As a result, the number of tests has also dropped.

The decline of early prostate cancer diagnoses

The declining rate of diagnosis of early prostate cancer has contributed to a continuing controversy over the disease. 

In 2012, the USPSTF recommended against digital rectal exams to check the size of a man’s prostate and prompt possible further evaluation. Afterwards, diagnoses of early prostate cancer in American men aged 50 and older dropped by 19 percent between 2011 and 2012 and by another 6 percent the following year.

The USPSTF does not recommend the PSA test for men 70 years and older. That’s because most prostate cancers grow so slowly that such men are likely to die with prostate cancer, but not from it.

The USPSTF suggests that men from ages 55 to 69 should decide if and when to be tested based on their personal risk factors.

Risk factors for prostate cancer

• You’re at more risk if you’re older than 65 or African-American.
• Having a father or brother with prostate cancer more than doubles your risk.
• Eating lots of dairy products may increase your risk slightly.
• Men with obesity may be more likely to get the more aggressive form of cancer.

Symptoms of prostate cancer

If you have symptoms of prostate cancer, it’s essential to see your doctor. Early symptoms of prostate cancer include:

• Frequent urination
• Weak or interrupted urine flow or the need to strain to empty your bladder
• The urge to urinate frequently at night
• Blood in your urine
• New onset of erectile dysfunction
• Pain or burning during urination, which is much less common

Watchful waiting is safe for prostate cancer

Some doctors follow a protocol of regular PSA tests. But testing has a downside. If your PSA numbers are elevated, your doctor might suggest a biopsy, which can lead to false positive results and unnecessary treatment, including surgery or radiation that can lead to incontinence or impotence.  

Even if you do have cancer, you don’t always need to take action. Research suggests that men diagnosed with early prostate cancer can safely choose to monitor it (watchful waiting, also called active surveillance). Their chance of dying from prostate cancer over the following 10 years is the same as for men who treat it.

In one study, the rate of prostate cancer deaths was very low.

“Virtually no one had died from prostate cancer,” said Mark Litwin, MD, chair of urology at the David Geffen School of Medicine at UCLA. “That should give all men pause before pursuing radical treatment for low- or intermediate-risk tumors.”

Another study, meanwhile, calculated 1.5 million cases of overtreatment.

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