Watchful waiting and Active surveillance for prostate cancer

Contrary to what a lot of people believe, prostate cancer treatment options do not start and end with surgery, radiation or hormone therapy. There are two other treatment options for prostate cancer that need to be discussed and evaluated in almost every newly diagnosed gentleman with this disease. And these are – Watchful waiting and Active surveillance.

Watchful waiting implies withholding active treatment for prostate cancer (surgery, radiation or hormone therapy) in men with advanced age or multiple medical problems till they develop significant symptoms from the disease. It is considered in men with early prostate cancer, who have a limited life expectancy of less than 5 to 10 years and have not yet developed significant symptoms from their disease. It is based on the premise that a significant proportion of men with prostate cancer have slow growing disease and hence will not be affected by it in their expected lifetime. It is very important to note that AGE should not be the sole criterion for applying watchful waiting in patients. I have come across many patients even in their late 70s who enjoy excellent health and have a life expectancy of at least 10 to 15 years and more. These are the patients who are very likely to benefit from active treatment for prostate cancer with surgery or radiation.

Active surveillance, on the other hand, is a treatment option for very early stage of prostate cancer which is expected to be localised within the prostate and has not spread beyond it. It can be applied to men with less aggressive types of this disease and can be recommended as an alternative to immediate treatment with radiation or surgery. For active surveillance to be considered, ALL of the following conditions should me met in the evaluation of the patient:

  • PSA should be less than 10 ng/ml
  • Gleason score in the biopsy should be 3+3 = 6; Men with Gleason 7 or above prostate cancer are not good candidates for active surveillance in most circumstances
  • In the biopsy report, not more than 2 cores should be positive for prostate cancer
  • There should not be an involvement of more than 50% of any core with prostate cancer
  • Clinical stage should be T2a or less (This is determined by your doctor on physical examination of the prostate)

If all the above criteria are met, a serious thought should be given to proceeding with active surveillance and withholding immediate treatment for prostate cancer. Active surveillance involves regular physical examination and PSA tests every 3 months, and a prostate biopsy repeated every year to ensure that the cancer is not becoming more aggressive. In case it is found that the cancer is increasing in volume or aggressiveness, immediate treatment is indicated. It has been found that by following this strategy, up to 70% of patients fulfilling the above criteria can safely avoid surgery, radiation or hormone therapy for prolonged periods of time with attendant benefits in terms of improved quality of life and decreased complications.

In summary, it is important to have a discussion with your doctor about all the treatment options for prostate cancer including active surveillance and watchful waiting. It is also a good idea to seek a second opinion from another source to increase your knowledge and reach an appropriate decision for individualizing treatment for prostate cancer depending on the person’s medical conditions, disease status and preferences.

This article has been written by Dr. Gagan Gautam, Head of Urologic Oncology & Robotic Surgery at Max Institute of Cancer Care, New Delhi, India. Besides being India’s leading robotic surgery expert  for prostate cancer, Dr. Gautam is also closely involved in the counselling and individualised care of men afflicted with this disease. His major focus is directed towards helping men in selecting and receiving the best treatment option for prostate cancer based on their personal medical conditions and preferences.

View Dr. Gautam’s profile here

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To read about robotic surgery for prostate cancer, please click here

To read about recovery after robotic surgery, please click here

To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here

To see a video of robotic surgery for prostate cancer, please click here

To read about the cost of prostate cancer treatment in India, please click here  

Cost of prostate cancer treatment in India

Being told by a doctor that you have been diagnosed with prostate cancer is probably one of the most traumatic experiences that anyone can have. The road ahead becomes uncertain and every step seems tricky and arduous. There is little doubt that prostate cancer extracts a psychological cost from the person it afflicts and also from his near and dear ones. This impact can be lessened by a compassionate and confident healthcare provider and perhaps more so, by caring and understanding family members.

The next step ideally involves an informative exchange of information amongst all stakeholders to ascertain a coherent plan of treatment. One of the major realities that one has to face in this situation is the cost of prostate cancer treatment, specially since this financial burden is often unexpected and unplanned for in a country like India, where the vast majority of population does not have medical insurance. What follows are a few important pieces of information about the expected cost of prostate cancer treatment in India, which fortunately, is still way below that seen in most parts of the world.

I shall be covering three established prostate cancer treatment options – Surgery, Radiation therapy and Hormone therapy. Other treatment options like HIFU, Cryotherapy and Cyberknife cannot be routinely recommended for the treatment of prostate cancer in India currently, since they are in an early phase of adoption with little information available about their long term outcomes and complications. Moreover, the discussion on how to choose the right treatment for prostate cancer is beyond the scope of this blog and will be addressed in another post.

Hormone therapy: Hormone therapy or Androgen Deprivation Therapy (ADT) as it is called in medical terminology implies the use of injections to suppress the level of Testosterone (male hormone) in the body to near – zero levels. This acts to decrease the growth and spread of prostate cancer for a duration of time ranging from a few months to a few years. While it is the mainstay of treatment for prostate cancer which has spread to other parts of the body (stage 4 or metastatic cancer), it is NOT recommended as the ONLY treatment for most cases of prostate cancer which is limited to the prostate region (localized prostate cancer) since it does not cure the disease but only controls it for some time. Invariably, with time the cancer starts becoming resistant to hormone therapy and starts spreading after that. The cost of hormone therapy ranges from 16,000 – 30,000 INR for an injection, which is to be given every 3 months. Some of the brands available in India are Zoladex®, Lucrin®, Eligard® and Pamorelin®.

Important points to discuss with your doctor:

  • A more expensive injection is not necessarily more effective. One should go for a cheaper, yet trusted brand to ensure that adequate effectiveness is achieved without excessive financial burden.
  • An injection imported from outside India is not necessarily more effective than an indigenous version.
  • You can often get these injections at up to 20% less than the MRP if you directly purchase it from the company representative. Your doctor should be able to provide you with the contact details.
  • Be careful about the storage requirements of the injection. Some of these require to be kept refrigerated during transportation and storage to maintain effectiveness.
  • A longer acting version (6 months) may be a cheaper option than two 3 monthly injections.
  • Removal of testes (surgical castration or bilateral orchidectomy) is a less expensive alternative to injections in the long run but is associated with an adverse psychological impact due to changes related to body image.

Radiation therapy: Radiation treatment is an alternative to surgery in patients who have prostate cancer that is localized to the area of the prostate and has not spread to other parts of the body. In most circumstances, radiation therapy needs to be combined with hormone therapy for 2 to 3 years in order for it to come close to the effectiveness and cure rates of surgery alone. Image Guided Radiation Therapy (IGRT) is currently the standard benchmark for the radiation treatment of prostate cancer in India. It is delivered over 6 to 8 weeks with 5 daily sessions in a week. The cost ranges from 2.0 – 2.5 lacs (200,000 to 250,000 INR) in most private institutions in the country with advanced radiation facilities. The addition of hormone therapy to this treatment increases the cost by about 65,000 to 1,20,000 INR per year bringing the total cost of treatment to about 4.0 to 6.0 lacs (400,000 – 600,000 INR), albeit spread over 2 to 3 years.

Brachytherapy, which is a form of radiation for early prostate cancer, involves the placement of radioactive ‘seeds’ in the prostate under the guidance of an ultrasound machine. These seeds need to be imported from abroad and the treatment can cost anywhere from 5.0 – 8.0 lacs (500,000 – 800,000 INR) depending on the number of seeds required and the prevailing currency exchange rate. It is one of the more expensive options for treatment, especially if it is combined with hormone therapy.

Surgery: The complete removal of the prostate, along with the adjoining structures (seminal vesicles, lymph nodes etc.) done with an intention to cure a patient of prostate cancer is called Radical prostatectomy. It can be performed in an open conventional manner or with laparoscopy or robotic surgery. Robotic surgery for prostate cancer is now available in the country and is currently considered by many to be the best treatment for prostate cancer in India. It has the advantages of a faster recovery, greater precision and lesser complications as compared to conventional surgery for prostate cancer. The cost of robotic prostate cancer surgery in India is usually in the range of 3.5 to 4.0 lacs (350,000 – 400,000). While this cost is about 30% more than that of conventional surgery, some of this gets offset by the earlier discharge from hospital, less medication use and decreased chances of additional treatment due to decreased complication rates with robotic surgery.

In summary, while the ideal treatment for prostate cancer in a particular patient differs from individual to individual based on their age, overall health status and stage of the disease, cost considerations do play a major role in the decision making process. All these implications should be discussed with your doctor in order to arrive at the most suitable decision.

This article has been written by Dr. Gagan Gautam, who is the head of urological cancer surgery and robotic surgery at Max Institute of Cancer Care, New Delhi, India. He is fellowship trained in robotic cancer surgery from the University of Chicago Medical Center, USA and is currently the leading robotic surgeon for prostate, kidney and bladder cancer in India. His institution, Max Hospitals, Saket, New Delhi is an 800 bedded tertiary hospital located just 20 min away from the International airport. It is an NABH accredited institution and is recognised as one of the best hospitals for prostate cancer treatment in India. It is equipped with state of the art diagnostic and therapeutic infrastructure including the Da Vinci Xi HD robotic surgical system, which is used by Dr. Gautam to perform robotic surgery on his patients who travel from all over India and other parts of the world.   

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 To know more about robotic surgery for prostate cancer, please click here

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To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here

To read about active surveillance and watchful waiting for prostate cancer, please click here