The most common presenting symptom for someone with pancreatic head cancer is painless progressive jaundice. The prognosis for inoperable pancreatic cancer is grave. Surgical resection is the only curative options. For those jaundiced patients with operable pancreatic cancer, some clinicians will insist on relieving the jaundice before surgery. This is achieved by placing a plastic stent into the common bile duct to re-establish bile flow into the duodenum. Usually this means a delay of 4 to 6 weeks before surgery can be performed. (The rationale for relieving the jaundice is to reduce the risk of developing hepato-renal syndrome.)  However, some surgeons will operate immediately without relieving the jaundice, believing that stenting before surgery increases the post-operative complications rate. The argument of ‘to drain or not to drain’ before surgery has been raging for more than 2 decades.

A multi-centre, randomised study on 202 patients with pancreatic head cancer was recently completed in the Netherlands (N Engl J Med 2010; 362: 129 – 137). The researchers compared pre-operative biliary drainage (for 4 – 6 weeks) with subsequent surgery against surgery alone in order to determine the rate of serious complications within 120 days after randomization in these 2 groups of patients. The rate of serious complications in the early surgery group was 39% while that in the biliary drainage group was 74%. The surgery-related complications rate was 37% in the early surgery group compared to 47% in the biliary drainage group. This study thus showed that routine pre-operative biliary drainage increases the rate of complications in patients with jaundice secondary to pancreatic head cancer.

Despite this study, there will still be clinicians who routinely perform pre-operative biliary drainage for these patients because they believe this will reduce the risks associated with surgery in the presence of jaundice. As it is very difficult to complete a study with very large number of patients with pancreatic head cancer, the controversy of ‘drainage’ versus ‘no drainage’ will unfortunately continue.

When your doctor tells you that you have developed an early cancer, your most likely response would be ‘Can it be completely removed?’ or ‘What needs to be done in order to cure me?’  Imagine what your response would be if your doctor said “Just wait and see. Doing nothing is just as good”. You might accuse him of being negligent and proceed to change your doctor.  However, according to one recent study, masterly inaction may well be the best option for some patients with early prostate cancer.

Researchers from the University of New Jersey studied 14,516 men aged 65 years or older diagnosed with stage T1 or T2 prostate cancer during the period 1992 – 2002. These patients did not have surgery or radiation treatment and were followed up for a median of 8.3 years by active surveillance only (JAMA 2009; 302: 1202 – 1209). The median age of these patients was 78 years. The 10-year overall survival of these patients was 94%. Indeed, it would be difficult for active surgical treatment to better this survival figure as shown in an earlier Scandinavian study (N Engl J Med 2005; 352: 1977 – 1984). This study compared the survival of prostate cancer patients treated with prostatectomy against watchful waiting in 695 men (mean age of 64.7 years) with early prostate cancer. The 10-year overall survival of the prostatectomy group versus the watchful waiting group was 90.3% versus 85%; this difference was statistically significant.

The best way to treat early prostate cancer detected by prostate specific antigen (PSA) screening is still being debated. That is why there are many ongoing randomized trials investigating various approaches for treating early prostate cancer. What the above US observational study has demonstrated is that there is increasing evidence showing that a vast majority of men with early prostate cancer, detected by PSA, have a very good prognosis. Even if they are not treated with surgery, radiation or hormone therapy, they are unlikely to die of prostate cancer or suffer serious consequences from its spread at 10 years or more. While this may be the right approach for patients who are 70 or older, it may well not be the right approach for someone who is 50. The question of early intervention or masterly inaction is being addressed in 2 ongoing randomized clinical trials – PIVOT in the United States and PROTECT in the United Kingdom. The aims of these trials are to evaluate the overall and disease-specific survival and quality of life after early treatment versus conservative management in men with localized prostate cancer detected primarily with PSA testing. The results should be available in a few years.

In medicine, masterly inaction is practiced and sometimes doing nothing can turn out to be the best treatment. It is natural for any patient to find it difficult to accept the fact that doing nothing can be the best treatment in some medical conditions. The doctor’s job is to weigh up the pros and cons of being active or doing nothing. After presenting you with the facts, you still have to decide.

The next time your doctor suggests some management option which sounds controversial to you, hear him out before firing him.