Warren Buffett's decision to undergo radiation treatment for his stage 1 prostate cancer underlines how much a man's choice reflects personal values as much as medical evidence.
Stage 1 prostate cancer, in which the malignancy is confined to the prostate gland, "has an excellent long-term prognosis and is in such a curable stage that a patient has several equally valid options," said Dr. Jonathan Wright, a urological oncologist at the University of Washington and the Seattle Cancer Care Alliance.
Those options include active surveillance and radiation therapy.
With active surveillance, previously called watchful waiting, the man is monitored for a sudden growth of the tumor but is not treated. Since that is considered as valid an option as radiation for stage 1 prostate cancer, some experts wondered why Buffett chose to be treated.
"A good number of men with low risk cancer of the prostate can be observed without needing to be treated," said Dr. Louis Potters, chairman of radiation medicine at North Shore-LIJ in New York. "In men who are octogenarians with low-risk cancer of the prostate, where the likelihood of death is very low, the first thing that comes to mind is, can we put them on active surveillance?"
Such "super-low-risk tumors don't need to be treated at all," said Dr. Mark Litwin, a researcher at UCLA's Jonsson Comprehensive Cancer Center and chairman of the Department of Urology. Agreed Wright, "Because this is such a low-risk cancer, active surveillance is a reasonable option."
But some of the 241,000 men who will be diagnosed with prostate cancer in 2012 are not comfortable foregoing treatment.
What a man and his doctor choose "depends on three factors," said Litwin. "How bad the cancer is, how healthy the patient is, and personal preference. Some patients just say get it out of me," and don't want to suffer the anxiety of waiting for a tumor to suddenly start growing or spreading.
Buffett, 81, is thought to be quite healthy, which may have influenced his choice.
"For someone in his age group, the big question is how does the risk of death from prostate cancer compare to the risk from other causes," said Litwin. "As we age, these other causes of mortality increase, and prostate cancer becomes relatively less likely" to cause death.
"But even older men, if they are in good health, might view their risk of death from heart disease, stroke, and other common conditions as unlikely enough that prostate cancer looms as a larger threat," said Litwin. "That makes them decide to treat it rather than opt for active surveillance."
One consideration in opting for treatment is that radiation therapy - Buffett will undergo daily treatment for two months, beginning in July - has few if any side effects.
"The radiation will be delivered in short doses, daily over two months," said Washington's Wright. Since the beam is extremely focused, the only side effects should be mild fatigue and a temporary worsening of urinary and bowel function.
But "those dissipate quickly," said Wright. "A patient is usually able to work while receiving radiation treatment."
Buffett's cancer was diagnosed through PSA (prostate specific antigen) screening. The U.S. Preventive Services Task Force recommends that men over the age of 75 not undergo PSA screening.
"So why were they really screening him?" asked North Shore's Potters. "Maybe it's more aggressive, maybe it's not so benign. Because if it's really benign, one could question why he was screened and why he's being treated."
Other experts, however, emphasized that the choice of radiation could simply reflect personal preference, noting that a recurrence of prostate cancer is not treated with radiation.
"If a patient has a recurrence of (previously treated) prostate cancer, he would get androgen-deprivation therapy," said Washington's Wright. That treatment prevents androgens -male hormones - from fueling the growth of the cancer.
Buffett's decision to postpone radiation treatment until July also suggests that his physicians do not view his situation as urgent.
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