Final results of the PIVOT trial offered no dramatic surprises, but reassuring confirmation of the increasingly accepted belief that watchful waiting is the best approach for low-risk prostate cancer. (N. Engl. J. Med. 2012; 367:203-213).
A thoughtful accompanying editorial offered perspective on this and other recent trials that suggest widespread use of aggressive treatments following detection of prostate cancer by PSA screening offer a "marginal benefit on the lifespan but at a considerable cost." Surgery and other radical procedures should be reserved for high grade "cancers that matter" – those most likely to be lethal, argue Dr. Ian M. Thompson Jr. of the University of Texas Health Science Center in San Antonio, and Catherine M. Tangen, Dr.P.H., of the Fred Hutchinson Cancer Research Center in Seattle.
Unfortunately, the findings will not put to rest the anxiety inherent in men who will be faced with decisions about whether to opt first for PSA screening, then for biopsies based on screening, and then for an array of possible treatments based on biopsy results. For many of those men, it will be hard to just say no.
Dr. Durado Brookes, director of prostate and colorectal cancer programs for the American Cancer Society, was quoted by the Los Angeles Times as saying, "When most men are told they have prostate cancer, their immediate thought is, ‘Oh my God, I’m going to die,’ and their immediate next step is, ‘Let’s do something about this.’ "
Action, rather than deliberation, is certainly the go-to position for most American men. For those who struggle with anxiety, knowledge that a cancer lies within their bodies may seem even more excruciating than going through with procedures that they might not actually need, and that may cause them harm.
In counseling anxious patients, psychologists focus on cultivating "distress tolerance." Patients learn to recognize physical and emotional signs of exaggerated panic, and to develop coping skills that essentially tell the brain’s deep fear center, the amygdala, to "chill out," as they logically contemplate the true scope of a perceived threat.
It takes practice, and patients often resist talking about or even thinking about the looming objects of their distress. But exposure to the threat, scientists have found, is key. And the good news is, cognitive and behavioral therapy for anxiety is quite successful for most patients, even using short-term interventions.
Talking to men with low-risk prostate cancer about the wise option of "watchful waiting" takes special skill, to convey the facts while competing with the hair-on-fire amygdala-fueled rants going on inside his head and the adamant opinions of his sister-in-law, neighbor, and the guy on his bowling team that he needs to get to surgery, and pronto, since "watchful waiting" is just part of the conspiracy to ration care.
What I think will help is to review with such patients the evolution of your own thinking about treatment of early-stage prostate cancer, explaining what research and clinical experiences led you to offer the advice you do.
Provide links to web sites or summaries that clearly summarize the latest research, and offer, if you can, a follow-up appointment to discuss what your patient has read.
Finally, tell the patient you care about him personally: his goals, his relationships and sexuality, and the quality of his life, as well as his lifespan. Let him know that you consider it a relief that he doesn’t require radical treatment because he doesn’t have what Dr. Thompson and Dr. Tangen would consider a "cancer that matters." Because he does matter, very much.
Your patients can tolerate the distress of "watchful waiting." It’ll get easier for them over time, as they live their lives well.
Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.