Despite sounding counterintuitive, sometimes it makes sense to monitor—but not treat—certain types of cancer. Physicians call the approach “watchful waiting” and recommend it for some conditions that progress slowly or when the therapy’s risks outweigh the benefits.
Unlike inpatient observation that typically lasts for hours or days, watchful waiting is an outpatient strategy that can span years. Checkups, tests and other measures help doctors detect signs that would prompt considering active treatment.
Though watchful waiting is not a new option for cancer patients, some public misperception about it remains.
“I think some people think that it means, ‘Don’t worry about it,’” says Louis Eichel M.D., chief of Rochester General Hospital’s urology division and partner at the Center for Urology, which has four offices in the Rochester area. “For any kind of cancer, that’s really not the case. There’s ongoing surveillance that is necessary.”
The strategy also requires communication.
“It’s an ongoing conversation with the patient, and they’re participants in the process as well, looking out for symptoms, (doing) self-exams and the like,” says Michael Becker M.D., director of the blood and marrow transplant program at UR Medicine’s Wilmot Cancer Institute.
Now widely accepted as an approach for ear infections and back pain, watchful waiting has become an option for prostate cancer patients because treatment for that condition can lead to impotence and incontinence.
Determining which patients would benefit from watchful waiting involves what doctors call “risk stratification.” An 80-year-old man, for example, who has coronary artery disease and low-grade prostate cancer would likely be suitable for watchful waiting.
“But if you diagnose a 50-year-old man who has, let’s say, two or three cores (from a needle biopsy) positive for prostate cancer and whose father may have died of prostate cancer, that person is not a candidate for watchful waiting,” says Jean Joseph M.D., director of the Center for Robotic Surgery and professor of urology and oncology at the University of Rochester Medical Center.
“Not all cancers kill, and not every man has the same risk,” he adds. “But we also have to look at the risk of the treatment. … The point is not all cancers are the same, and not all individuals should be treated the same. Treatment should be personalized or individualized.”
For reasons scientists do not yet understand, African Americans have higher rates of incidence and death from prostate cancer than whites and other minorities. That influences the issue of watchful waiting, “but I think age and co-morbidities are bigger factors,” Joseph says.
Patients often ask if delaying treatment for low-risk prostate cancer will make the condition tougher to treat down the road, but that concern is unfounded.
“It’s rare to get into a situation where it’s too late to intervene successfully” in those cases, Eichel says. “It’s not impossible, but the majority of the time, you can intervene while the prostate cancer is still potentially curable.”
Though some patients welcome taking a wait-and-see approach to surgery and radiation, others feel that it would rattle them.
“There are some patients who are simply not comfortable with the idea of having cancer in the body and not doing something about it,” Eichel says. “They feel like there’s a time bomb inside them, and their quality of life would be impacted very badly just by knowing that and having to worry about it all the time. Those people truly are better off just being treated because it alleviates that anxiety.”
A patient’s comfort level with watchful waiting can depend “on the amount of education and time spent by the physician and his team on outlining what their cancer is, what the cancer will do when it progresses, what symptoms the patient should be on the lookout for, and having them understand that diving in immediately with treatment has not been shown to impact the course of the disease,” Becker says.
Beyond urologic health, watchful waiting is a strategy for coping with blood conditions, such as chronic lymphocytic leukemia, or CLL. Often appearing during or after middle age, the disease occurs when the bone marrow makes too many lymphocytes, a type of white blood cell that is part of the immune system.
Chronic lymphocytic leukemia’s symptoms include fever, infection, weight loss and enlarged but painless lymph nodes, but some patients do not have any early symptoms and may never need treatment because the disease can grow slowly.
“In the hematologic malignancy world, there are clinical trials that looked at aggressive care upfront versus watchful waiting, and we can identify those patients who may benefit from early intervention versus just watchful waiting, based on clinical features of their disease,” says Becker, whose aunt-by-marriage has had asymptomatic CLL for 20 years.
Monitoring CLL patients who choose watchful waiting involves physicians performing clinical exams and keeping a close eye on white blood-cell counts and bone-marrow function. It also calls for active listening when patients give their medical history.
“So it really is an ongoing dialogue,” Becker says. “And that’s important—that (patients) understand what the implications of therapy are, what it can and cannot do, and help us to be on the lookout for evidence that the disease in progressing.”
Sheila Livadas is a Rochester-area freelance writer.
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