Who needs treatment?

It seems a strange question to ask; surely everybody with cancer needs treating? Let me tell you a story about prostate cancer. This has suddenly got a lot commoner than it was. In the US it about 6 times as common as it was 30 years ago and in the UK about twice as common. The reason, of course, is prostate specific antigen (PSA) testing. Not everybody with a raised PSA has prostate cancer; in fact two thirds of men with a raised PSA don’t have prostate cancer. But the only was to be sure of that is to do a prostatic biopsy.

Said quickly that sounds simple. In practice it is most off-putting. A plastic probe one centimeter in diameter and nine inches long is covered in KY jelly and inserted through the anus. When positioned correctly by ultrasound guidance it is pressed against the front of the rectum and a biopsy needle fired. It feels like a dull thud hitting the prostate gland, but it doesn’t hurt exactly, unless it happens to catch a nerve. If it does then it causes an eye watering pain extending from the prostate down to the tip of the penis. When this has subsided, the operator does it again. Nine times.

You get the result a week or so later. Likely it will be benign, but if it shows cancer you then have the agonizing decision of whether to have surgery or just watch and wait. If you choose surgery you’d better choose your surgeon and carefully scrutinize his complication rate. For among the complications of successful surgery are incontinence and impotence. I remember a featured article in Reader’s Digest. The author was so grateful that he had a PSA test. He made a point of stressing how much his wife sympathized with him over his impotence.

Prostate cancer is currently three times as common in the US as in the UK. But the death rates in the two countries are exactly the same. Better surgeons in the US? Or better case selection in the UK?

With CLL the CBC is the screening test and people get one, not because they are looking for CLL, but for any and every other reason. Three-quarters of patients diagnosed with CLL have no symptoms referable to CLL when they have that first blood test.

In 1999 a large meta-analysis of several trials with 10 years of follow-up proved that there was no advantage for early treatment over waiting until symptoms began. Indeed in 1995, after 6 years of follow-up there was a possibility that those treated early did worse.

The problem with this analysis was that the treatment offered was old fashioned chlorambucil. Not only that, but the trial took in all comers; had they selected only those with bad prognostic markers the outcome might have been different, especially had they used one of the more recent treatment that give more complete remissions. This is a question still waiting to be answered, but trials are going on now in Europe to try and answer it.

In the meantime we are all signed up not to treat until the NCI guidelines are fulfilled. These are the NCI guidelines:
One of the items on the following list must be present:
1] Weight loss of more than 10% of body weight in the previous 6 months;
2] Extreme fatigue so that the patient cannot work of perform usual activities;
3] Fevers of greater than 100.5°F for at least 2 weeks without evidence of infection;
4] Night sweats without evidence of infection. They have to be severe.
5] Evidence of bone marrow failure shown by the development of, or worsening of, anemia or thrombocytopenia.
6] Autoimmune hemolytic anemia and/or thrombocytopenia poorly responsive to corticosteroids.
7] Massive splenomegaly (>2.5 inches below the ribcage).
8] Massive lymph nodes or clusters of nodes (>4 inches in longest diameter).
9] Increase in lymphocyte count by >50% over two months or an anticipated doubling time of <6 months.

However, a high lymphocyte count is not in itself an indication for treatment. For everybody else it is wait and worry or join one of those European trials of early treatment, or find a physician who likes to bend the rules a bit.