Dear Dr. Roach: In a recent column regarding concussion, you made a statement that 鈥測ou should remember that treatment is almost always better sooner than later.鈥�
That raises some concern for me with my present situation. I am a 70-year-old active male and recently have had prostate cancer diagnosed.
Out of 12 biopsies, one had traces of cancer. I am now a Gleason six. The surgeon recommended that I go on active surveillance and come back in six months for another prostate-specific antigen test, which had been 6.3 and rising in the recent past. He said this appears to be a slow-growing cancer and may never cause me any problem. However, it is up to me as to what I want to do. I鈥檓 otherwise very healthy.
I am curious as to your thoughts. Is this also a case whereby being proactive and doing something now could be better than waiting until later?
D.N.W.
This is, in general, a difficult question, with reasonable physicians holding different viewpoints.
For your particular situation, you appear to have clinically localized, very-low-risk prostate cancer, since your PSA is less than 10, your Gleason score (a measure of how aggressive the cancer appears on the tissue sample under the microscope) is six, and you have only one out of 12 core samples positive for cancer.
Your urologist has recommended the usual approach, which is active surveillance with plans to begin definitive treatment if there is any indication of progression of the cancer. 鈥淒efinitive treatment,鈥� in this context, means radiation (via external beam), brachytherapy (radioactive 鈥渟eeds鈥� placed in a single outpatient visit) or surgery. There are no randomized trials to compare early treatment versus active surveillance.
I put your information into an online decision-making tool (available at mskcc.org/nomograms/prostate), which shows you have an excellent chance (99 per cent at 10 years) of cancer-specific survival if you were to choose surgery.
However, most men would have an excellent outcome with no treatment (in a study following men of similar risk to yours, 98 per cent had cancer-specific survival at 10 years). About 70 to 80 per cent of men your age have prostate cancer, most of whom will never know they have it and it will never bother them. Importantly, surgery has significant risk of side effects, including difficulty with sexual and urinary function.
My opinion is that early treatment probably increases likelihood of survival by a very slight amount, at the cost of an increased risk of significant side effects. Since your prognosis is so good, I agree with the recommendation for active surveillance, but it is your decision.
听
Dear Dr. Roach: Have there been any studies on Xarelto versus Eliquis, as to which is better? My heart doc wants me to change to Eliquis. He says it provides for less bleeding.
R.B.
There have been no comparative trials among the newer anticoagulant medications, including Pradaxa (dabigatran), Xarelto (rivaroxaban) and Eliquis (apixiban). All of them have similar or slightly less bleeding risk than the older drug Coumadin (warfarin).
On the other hand, if there is a serious bleed on one of these, there is no way to stop it. This is opposed to warfarin, which has a treatment in the case of excess bleeding.
Your doctor may be relying on his or her experience or on the drug company鈥檚 marketing, which showed a significantly lower bleeding risk than warfarin. However, these results can鈥檛 be used to compare the three newer agents.
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