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.

Colorectal cancer (CRC) is now a common cancer in both the western and eastern countries. Apart from the regional lymph nodes, the next most common site for colorectal metastases is the liver. In the past, these patients, when treated solely with fluorouracil / leucovorin, would have an overall survival of 8 – 12 months only. With the advent of safer liver surgery and better chemotherapeutic agents, most doctors have the distinct impression that the outlook for patients with metastatic colorectal disease has improved over the last 10 years. Is this observation correct?

Researchers from the University of Texas M D Anderson Cancer Center and the Mayo Clinic performed a retrospective review of 2470 patients with metastatic CRC treated at the Mayo Clinic (n=856) and MD Anderson (n=1614) during the period 1990 to 2006 (J Clin Oncol, epub 2009 May 26). From 1990 to 1997, the median overall survival for patients with metastatic CRC was 14.2 months. However this improved to 29.2 months for the time period 2004 – 2006. The overall 5 year survival rates showed similar improvements, from 9.1% in the 1990 – 1997 period to 19.2% for the 2001 – 2003 period.

Overall Median Survival – 1998 to 2006

Overall 5-Year Survival Rates – 1998 to 2006

From 1990 to 2006, 231 patients had liver resection for metastatic CRC. Liver resections were performed with increasing frequency from 1998 and between 2000 and 2006 approximately 20% of patients had liver surgery. From 1998 to 2006, the 5 – year survival rate among patients who had undergone liver resection was different from those with unresectable disease. The 5 – year survival rate was 55.2% for resected patients compared to 19.5% for unresectable patients. The median overall survival for these 2 groups of patients was 65.3 months and 26.7 months respectively.

Survival analyses of patients with metastatic CRC who could not undergo liver surgery but treated with chemotherapy only, showed that the survival rates from 1998 to 2000 were not different from that before 1998. From 2001 to 2003, the survival rates improved only minimally but improved significantly for those diagnosed between 2004 and 2006.

In the last 5 years, newer chemotherapy drugs have made a difference to patients with metastatic CRC. It has improved overall survival and in some cases, can convert metastatic CRC into a ‘chronic’ condition. However, chemotherapy alone cannot provide a cure. If liver surgery can be performed, it can potentially provide a chance to cure. Even if it could not cure, liver surgery can significantly increase your survival time. While liver surgery is a very major operation, it is very safe when performed properly. Even though it is a big operation, it does not mean you will have a long hospital stay. Can you hazard a guess on the average length of hospital stay for someone undergoing liver surgery for metastatic CRC?

7 days!