‘Wait and see’ OK for some prostate cancers

Dear Dr. Roach: I am 58 years old and have early stage prostate cancer. My PSA is 6.5. How do you know when “wait and see” is the right approach? If I do need treatment, what are your thoughts about high intensity focused ultrasound (HIFU)? Why don’t some insurances cover the procedure?

T.B. “Wait and see” or “watchful waiting” was a strategy discussed in the 1980s. It came from the observation that a lot of prostate cancer behaved very indolently. Years could go by without the cancer causing problems. Since prostate cancer treatment, mostly surgery, risked the significant side-effects of incontinence and sexual dysfunction, urologists and oncologists reasoned that observation would cause a lot less harm than surgery. For some patients, the benefit of treatment was small.

This has evolved into “active surveillance.” This is appropriate for men whose cancers are low risk or very low risk. Instead of watching and waiting for something bad to happen, men in active surveillance have periodic evaluations of PSA and tumour size, and if the cancer becomes higher risk, they are treated aggressively.

To be in the lowest risk groups, the cancer must be small and contained within the prostate; nonaggressive based on pathology (a Gleason score of 6 or less); with few positive “cores” by biopsy; and having a low PSA “density.” Density is a measurement of how much PSA is made per gram of tumour. If your prostate cancer meets all these criteria, then active surveillance is an excellent option. Some men still choose to have the tumour treated, most commonly with surgery or radiation; however, there is little benefit and significant potential for harm from doing so for men in this lowest-risk group.

The strategy of surveillance for men in this group typically includes repeat PSA testing every six months, physical examination every 12 months and MRI or biopsy within the first year and again every two to four years. However, some men might have these numbers adjusted due to their unique situation.

The initial results for highintensity focused ultrasound look promising. However, a joint statement by several groups notes: “clinicians should inform patients considering HIFU that this treatment option lacks robust evidence of efficacy, and that even though HIFU is approved by the FDA for destruction of prostate tissue, it is not approved explicitly for the treatment of prostate cancer.”

I suspect the lack of explicit U.S. Food and Drug Administration approval of this procedure for prostate cancer is the reason it is not covered by some insurance.

Dear Dr. Roach: In a recent column on irritable bowel syndrome, you mention broccoli as a food to be avoided, citing the FODMAP diet. If you would look at the Monash University list of high-FODMAP foods, you will find that broccoli is low; however, cauliflower and other members of the brassica vegetable family are the culprits, being high in FODMAPs. Broccoli is one of the very nutritious vegetables that are allowed on this limited diet, and it would be a shame if people avoided it because of your widely read articles. I have IBS and have no trouble with broccoli.

H.M. I thank HM for writing. A recent update from Monash University notes that while the stalks of broccoli are high in overall FODMAPs — fermentable oligo-, di-, mono-saccharides and polyols, the chemical components of foods that often cause symptoms in people with irritable bowel syndrome — the flowers or heads are low. Consuming just the tops of broccoli should be welltolerated by most people. I want to reiterate that not everybody will have the same response, and consultation with a dietitian/ nutritionist remains a critical part of taking care of IBS and other gastrointestinal conditions.