Active Surveillance / Watchful Waiting

This segment of this website is devoted to Watchful Waiting, and Active Surveillance.

Active Surveillance is delayed treatment, which may result in having treatment if the man’s situation worsens.
Watchful waiting is never being treated, regardless of the man’s situation. The only time a man may do this is if he is very old or has other serious co-morbidities.
Some articles may use both names because the author may discuss both situations, but be very careful because the author may have a hidden agenda, unless he/ she specifically indicates what is the goal.




Topics                                                                                                           Paragraph Number 

Introduction 1.0
Many Doctors Ignore WW Safety Record 1.1
Discussion 2.0
Some men with Advanced Cases may wait for treatment 2.1
Huge percent of men don’t need treatment 2.2,2.3,2.4
Huge percent of men unnecessarily treated 2.10,2.11
Survival Rate of Treated and Delayed Treatment are Equal 2.4,2.5,2.6,2.7,2.8,2.9
Younger men May also do WW 2.9A
PSA Detected tumors often not as serious as Symptom detected cases 2.9B
Money & Fear of Malpractice law suits results in unnecessary treatment 2.9C
Patient Selection is Crucial for WW Protocol 2.9D
Quality of life Comparison for WW and Treated men 2.12
Epidemic of overtreatment of prostate cancer must stop 2.13
Watchful Waiting Criteria 3.0
All Treatments About Equally Effective for Low Grade PC 3.1
Comment 4.0
Percent of men who Stop WW to be Treated 4.2
References 5.0

1.0 Introduction

1.1 Many Doctors Ignore Active Surveillance Safety Record
Studies, Rationale and Statistics for Considering Active Surveillance.
Tens of thousands of men have, and are doing  Active Surveillance for many years without affecting their final outcome, however, many doctors say there is insufficient data to warrant doing Active Surveillance.
These doctors are not only ignoring the facts, they are perusing their own personal agenda. The following articles will illustrate how much is really known.
In the discussion section, are about a dozen of the 50 or 60 articles I have, that were written by, or quoted from, doctors who specialize in prostate cancer. These doctors have analyzed studies done in a number of countries, by much respected people in the prostate cancer field. These doctors have nothing to gain by “telling it as it is”. They are gently admonishing the doctors who are treating unnecessarily. You be the judge.

2.0 Discussion

2.1 Some men with Advanced Cases may wait for treatment.
Data from a number of studies, including a study at Memorial Sloan Kettering in NYC by Dr. Peter Scardino found that you can take one year to decide your treatment without compromise curability and the outcome, compared with immediate surgery – even in some advanced cases. (R208, R128A) (J. Natl. Cancer Inst. 2006;98:355-7).

2.2 Huge percent of men don’t need treatment.
Two-Thirds Of Prostate Cancer Patients Do Not Need Treatment.
Research at the University of Liverpool involving more than 500 prostate cancer patients has revealed two thirds (67%) did not require urgent treatment. . Studies have shown that men with non-aggressive prostate cancer can live with the disease untreated for many years, but aggressive cancer requires immediate treatment.
In the largest study of its kind, the international team of pathologists studied an initial 4,000 prostate cancer patients over a period of 15 years to further understanding into the natural progression of the disease and how it should be managed. The research was published in the British Journal of Cancer. Studies have shown that men with non-aggressive prostate cancer can live with the disease untreated for many years, but aggressive cancer requires immediate treatment.
Pathologists in the study showed that in more than 60% of cases the cancer could be managed by careful monitoring, rather than with active intervention methods, such as drug treatment or surgery.
Professor Chris Foster, Head of the University’s Division of Pathology, explains: ” it is important that we first understand the biological nature of the disease and how it will behave in each individual patient, before determining if and when a person needs a particular type of treatment.
We have shown that in the majority of cases, a specific marker is not expressed and therefore patients do not necessarily need to go through treatment to lead a normal life.” (Ref 214)

2.3 About 75 % of men with low grade prostate tumors that can be safely ignored for months or years receive aggressive treatment, despite the risk treatment of complications, researchers reported in the Archives of Internal Medicine on July 26, 2010 (NY Times, July 27, 2010)
Up to 70% of men who are diagnosed with PC through screening, receive treatment that they don’t need, according to Dr Otis Brawley, Medical Oncologist and Chief Medical Officer at the ACS. If the cancer seems to be growing, treat it, otherwise continue to watch it, Dr Brawley continued.
Dr Otis Brawley said, it is an American phenomenon that both doctors and PC patients feel it is necessary to do something.

2.4 Survival Rate of Treated and Delayed Treatment.
In a 2010 study, using a national cancer database, Swedish researchers found that among 2,566 men with cancer confined to the prostate gland, there was no evidence that men who delayed surgery more than one year had different outcomes than men who did not delay treatment. (US TOO Hotsheet 10/ 2010)
2344 men underwent surgery three months after diagnosis, and 222 men waited 19 months after diagnosis- most often prompted by a rise in their PSA levels or other signs of progression.
The long-term survival was nearly the same, according to the study findings published in the Journal of Urology. After eight years, 0.9 percent of men in the WW group had died, versus 0.7 percent of those who’d had immediate surgery.
Another reference indicating final outcome and the death rate for men doing WW is approximately equal to men who were treated. (R128A, R254, R239)
“Our findings show that if a man is diagnosed with a localized low-risk prostate cancer, there is no rush to decide which treatment choice (is) best,” lead researcher Dr. Benny Holmstrom, of Gavle Hospital in Sweden, told Reuters Health in an email.
A key difference between Europe and the U.S., Holmstrom said, is that active surveillance appears to be less commonly used in the U.S. This means that for some men, prostate cancer treatment can do more harm than good as treatment carries a risk of side effects — including long-term urinary incontinence and erectile dysfunction. According to the NCI, about half of the more than 190,000 U.S. men diagnosed with prostate cancer in 2009 would fall into this low-risk group.
A study published last year in the Journal of the National Cancer Institute estimated that since 1986, as many as 1 million U.S. men have received treatment for prostate tumors that would have never threatened their lives. (R128A)
Reference R208 quotes the NCI as saying a man can take one year to decide your treatment without compromise curability and the outcome, compared with immediate surgery.
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2.5 According to lead author Pär Stattin, a urologist at Umeå University, monitoring can be the best treatment for men with low risk prostate cancer, according to a study now being published in the Journal of the National Cancer Institute.
Professor Pär Stattin, and his associates evaluated the outcomes for 6,849 men aged up to 70 years in the Swedish National Prostate Cancer Registry (NPCR) who had a local tumor with low or moderately high risk of spreading.
With a median follow-up time of over 8 years, the risk of dying of prostate cancer within ten years was a total of 3.6 % in the group that did WW. In men who had surgery the death rate was 2.5 %, and in men who had radiation treatment the death rate was 3.3%. The risk of dying from causes other than cancer was nearly twice as high among men who were monitored. (Ref: R238 6/22/2010).
(Stan’s comment: The difference in death rates between treated and WW men was less than one percent even considering that Swedish men often had Gleason Score higher than what the US Criteria recommends).

2.6A – In a study to examine consequences of deferred treatment Active Surveillance (AS), 51,529 men were followed in the Health Professionals Follow-up Study, a prospective study. The conclusion in this nationwide cohort, more than half the men who opted for AS remained without treatment for 7.7 years after diagnosis. Older men and men with lesser cancer severity at diagnosis were more likely to remain untreated. PC mortality did not differ between AS and active treatment patients. (R246A)

2.6B – J. Stephen Jones, MD, Chairman, Dept. of Regional Oncology/ Cleveland Clinic, agreed with this when he said, “men who are treated after being on AS even after 5 years, fare just as well and still end up being cured”

2.7 Men who qualify for WW by meeting the AS criteria, “are unlikely to die of the disease even twenty (20 ) years later” The research was led by Dr Peter Albertson at the University of Connecticut, and appeared in the May 4, 2005 Journal of the American Medical Association.

2.8 Active Surveillance is safe.
In a study, in the Journal of Clinical Oncology, researchers at the Odette Cancer Centre at Sunnybrook Health Sciences Centre in Toronto, reviewed the medical records of more than 450 prostate patients who were considered of “favourable risk” — meaning their cancer was not considered aggressive or fast-growing. All were being managed with the watchful waiting approach called “active surveillance.”
The men were followed for up to 13 years, with the median follow-up time being 6.8 years. The researchers found that the rate of prostate cancer survival among the group was 97.2 per cent. Of the patients who did die during the study period, most died of causes other than prostate cancer. (R226)

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2.9A Younger men may also do Active Surveillance.
Dr. Laurence I. Klotz, is chief of the urology division at Sunny Brook Health Sciences Centre in Toronto, and is lead researcher of the Standard Treatment Against Restricted Treatment Study,   (START).  Dr. Klotz’s was interviewed on June 22, 2008 by a Star-Ledger reporter. Here is a portion of his statements, as well as other people on the topic of treating prostate cancer.
“Often, the PSA test leads to a biopsy that finds clinically insignificant prostate cancer, and yet the problem is the word ‘cancer’ creates a reaction that drives a lot of intervention
Klotz said up to half of all American men diagnosed with prostate cancer through PSA tests may meet the criteria for active surveillance, even those in their 50s.

2.9B-PSA detected tumors not as serious as Symptom detected cases.
In a trial, Dr. Klotz’s Canadian team already has followed 500 patientPSA detected tumors not as serious as Symptom detected casess who chose active surveillance. About a quarter eventually needed surgery because their PSA or biopsy indicated a change in the cancer. Six of the 500 men — or about 1 percent — died of prostate cancer. Researchers determined four men were incurable from the start because, in retrospect, it was clear microscopic amounts of their cancer already had spread at the time of diagnosis, Klotz said.  Others are alive, or died of other causes. (See Comment 4.3)
The same newspaper article had quotes from Dr. Ballantine Carter a urologist and researcher at Johns Hopkins Hospital.
Researchers said the tumors found when men have symptoms generally are larger and more lethal than those picked up through PSA tests. Cancers found through PSA screening may be so slow growing that they never cause harm. The Hopkins research, found that delaying surgery in closely monitored men did not worsen their outcomes.
“We are diagnosing men with a disease they would never know they had if they didn’t have a test in the first place,” said Dr. Carter. “You couldn’t find an academic urologist or any urologist who is honest who would not say we are over-treating prostate cancer,” he said. “The only question is, “To what extent?”
Johns Hopkins runs an active surveillance program that monitors more than 500 men with slow-growing tumors. Carter spends hours explaining the statistics to the men.
“A lot of people have tremendous trouble grasping the concept that they may have a cancer that is simply not going to harm them,” Dr. Carter said.

2.9CMoney & fear of malpractice law suits result in unnecessary treatment.
This article also included a comment by Virgil Simons, the founder and president of ProstateNet, a nonprofit patient advocacy center: Researchers and advocates for people with prostate cancer say several factors push the drive toward aggressive therapy, including a fear of malpractice lawsuits as well as money.  Doctors get paid considerably more for providing surgery or radiation treatments than for developing the long-term relationships and conversations that must take place when men undergo surveillance. “That’s the reality,” said Virgil Simons. (R228) (See comment 4.4)

2.9D-Patient selection is crucial for Active Surveillance.
Not part of the above article, Dr Klotz’s research found that after eight years, only one percent of 300 men on WW, died from PC. Selection is the Key to success. This was reported in 2006.

2.10-Huge percent of men unnecessarily treated.
Autopsies studies show one in three men age 50 or older have PC, and 80 percent are low grade. Up to 30 % are insignificant, reported Dr William C. DeWolf, Chief, Division of Urologic Surgery, at the Beth Israel Deaconess Medical Center, Boston MA., at a PC Educational Breakfast, on October 26, 2010. He also stated large active surveillance and active treatment programs have the same outcomes. Dr. DeWolf stated that 30% of 120 men have progressed over ten (10) years. Thirty percent of the men had “recurrences”, which means that seventy percent (70%) had successful Active Surveillance result.

2.11-Study Backs ‘Active Surveillance’ for Low-Risk Prostate Cancer.
Using a computer simulation model, researchers say they’ve determined that relying on “active surveillance” to follow men with low-risk prostate cancer is a “reasonable approach” and alternative to immediate treatment, which can cause unwanted side effects such as incontinence and impotence. “The intent of this study is to show that, on average, showing average disease-recurrence probabilities, active surveillance was an option,” said Dr. Julia H. Hayes, lead author of the study published in the Dec. 1 issue of the Journal of the American Medical Association.
Each year, some 200,000 U.S. men are diagnosed with prostate cancer. While about 60 percent of those men don’t actually need treatment, more than 90 percent will still be treated, said Dr. Hayes, who is a genitourinary oncologist with the Dana-Farber Cancer Institute and an instructor in medicine at Harvard Medical School. R341
Stan’s Comment: Usually I do not like computer models, but I am glad Dr Hayes found that Active Surveillance was a good approach for 60% of the men. I commend Dr. Hayes.
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2.12 Quality of life Comparison for AS and Treated men.
NCI Study Weighs Comparative Effectiveness of Low-risk Prostate Cancer Treatments.
When it comes to the treatment of low-risk prostate cancer, a National Cancer Institute comparative effectiveness study has concluded that the various approaches—including active surveillance, surgery, and radiation therapy—result in similar overall survival and tumor recurrence rates. However, compared with the immediate treatment options, active surveillance yields both a comparable net health benefit and more quality-adjusted life years for men age 65 and older, according to the economic model used in this study. (R128)
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2.13- Epidemic of overtreatment of prostate cancer must stop
The following is condensed from an article by Otis Brawley  CNN Contributor   Jul 21, 2014 

Editor’s note: CNN conditions expert Dr. Otis Brawley is the chief medical officer of the American Cancer Society, (ACS), a world-renowned cancer expert and a practicing oncologist. He is also the author of the book “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.”

This week, two important studies showing how prostate cancer is treated in the U.S. were published in the journal JAMA Internal Medicine. One is about Androgen Deprivation Therapy (ADT), and the other is about delaying prostate cancer treatment
These studies found that a large number of American men with prostate cancer get unnecessary and aggressive treatment. In some cases, these treatments are known to be worthless and even harmful.
One 20 year study of 60,000 men diagnosed with cancer confined to the prostate found that initial treatment with anti-androgen hormonal therapies is common. This study also confirmed previous research showing that this treatment in this population does not prolong survival, and cause a number of most undesirable side effects.
A second study showed that there is significant variation in how physicians treat good-prognosis (low-grade, less aggressive) cancer confined to the prostate. A substantial number get unnecessarily aggressive surgical or radiation therapies. These unnecessary therapies are also associated with significant harms.
A number of U.S. and European studies have shown that some prostate cancers are localized to the prostate and of good prognosis, meaning it rarely progresses or causes harm if left alone.
All of the organizations that set treatment guidelines based on the scientific evidence recommend that men diagnosed with this type of cancer be carefully observed and delay treatment.  These cancers can almost always be effectively treated if found to be progressing.With careful observation, the majority of men will never need treatment and can be spared the burdens of unnecessary therapy.
It is the physician’s responsibilityto tailor treatment to the patient and his cancer. These two studies form a long list of patterns of care studies showing that a number of American physicians who treat prostate cancer are not fulfilling this responsibility (See Comment 1)
Some will say that physicians are over-treating prostate cancer for profit. Although it is true that most American physicians get paid to treat patients and not to observe them, profit may not be a major motive. (See Comment 2)
Some treatments were drastically reduced, when Medicare took much of the profit out of administering the treatment by reducing physician reimbursement.
Some doctors will blame the epidemic of overtreatment on patient demand for aggressive cancer treatment, but the cooperation of the physician is still necessary to provide the unnecessary treatment. 
It is the physician’s responsibility to counsel the patient and even teach the patient what approaches are most appropriate. Overtreatment does not exist in Western Europe. (See Comment #3)
In some instances, unnecessary treatment of prostate cancer is curing some men who do not need to be cured, with significant detriment to their quality of life. The large number of “cured” makes aggressive treatment look good when one does not consider that many of the cured did not need to be cured.
A few of the doctors guilty of overtreatment may not understand the number and quality of the studies showing that there are “good cancers.” But most simply cannot accept the truth. (See Comment #4)
If we physicians claim to practice evidenced-based medicine, we must understand and respect the science and accept its findings. The science is very clear that there is some diagnosed prostate cancer that we can accurately predict as not needing treatment. These tumors are unlikely to progress, cause harm, and kill.
The technical term for this phenomenon is “overdiagnosis.” It has been estimated that overdiagnosis occurs in half of all patients with prostate cancer.
The ability to distinguish the cancers that need treatment from those that do not are relatively well-developed for certain prostate cancers and simply not used in the U.S.
In the paper describing their findings, Hoffman and associates note that some doctors’ treatment patterns are more appropriate than others. They suggest that public reporting of physicians’ cancer management profiles might enable primary-care physicians and patients to make more informed decisions about selecting physicians to manage prostate cancer. (See Comment #5)

™ & © 2014 Cable News Network, Inc., a Time Warner Company. All rights reserved.

To read the released article go to By David Ingram – email    The-CNN-Wire

Comments by Stan:

1-It has to be a huge number of physicians, because a few could not treat 90% of the men who have, and are, being treated.
2- A number of English, Canadian, and European doctors have said it is the profit motive in the United States).
3-Comment: It is the doctor’s duty to tell the truth and “do no harm”. It should be mandatory for the doctor to review & sign-off a patient’s Active Surveillance Criteria Form.  Doctors could easily convince the great majority of their patients of the safety and survivability record of Active Surveillance, if they chose to. Doctors rarely mention that the death rate of men treated shortly after diagnoses is the same as men doing Active Surveillance, and the Quality of Life is drastically better.
4- I believe the doctors do not want to accept the truth. Huge numbers of men delaying treatment are living a good Quality of Life, and living just as long as men who were treated shortly after diagnoses.
5- Public reporting could require the doctor to sign off on the patient’s Active Surveillance Criteria Form. A Medical Oncologist should also be required to assess the patient for the most objective opinion.

7 /31/2014
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3.0 Active Surveillance Criteria.
The following basic criteria have been agreed to by many major hospitals across the USA with slight variations. The 2010 Annual Report on Prostate Disease, a Harvard Health Publication (Page 69) lists three, slightly different sets, of similar criteria, The three sets are the Epstein Criteria, Named for Jonathan I. Epstein at Johns Hopkins), that was published in Journal of the American Medical Association in 1994. The Toronto Criteria, (authored by Dr Laurence Klotz) and The Beth Israel Deaconess Medical Center (Harvard Cancer Center) Criteria, authored by Dr. Marc Garnick. Every doctor will choose the criteria he prefers, depending on how conservative he wishes to be. Being ultra conservative will eliminate all but a few men from entering into a Active Surveillance program. (This is where the patient has to advocate for himself).
A- No Gleason Score above 3+3=6.{however, there are some exceptions. See below
B- No Gleason Grade of 4 or 5 detected
C- No more than three cores in a biopsy should be positive (contain cancer)
D- No biopsy core shall contain more than 50 % cancer. (Some doctors say not more than 30%)
E- The PSA doubling time shall be greater than one year. Greater than three years, based upon 8 determinations.
F- The PSA shall be under 10.
G- No seminal vesicle or lymph node shall be positive. If either of these are positive, waiting is not advised.
H- No distant metastases.
I – No lump detected by a DRE (T2a can do AS. T2b should not do AS)
Although one of the criteria for entering into a AS program is having a maximum Gleason Grade of 3+3=6, there are some exceptions if a score is 3+4=7. For example the amount of Gleason 4 may be very minute. The doctor and patient will have to discuss this as it is riskier to do AS. If your pathology report has your GG as 3+4=7, it may be worthwhile to have the slides reviewed by another hospital, because often another pathologist may interpret it as a 3+3=6. Some large hospitals have doctors who specialize in reviewing /reading pathology reports.
1-If the entire prostate is saturated with cancer, even if it Gleason Grade 6, AS is not advised.
2- If a tertiary Gleason Grade 5 was detected in five (5) percent or more of the prostate, as shown on the pathology report and the Gleason Score is 3+4=7, the score is up-graded to a Gleason Score of 8, which does not qualify doing AS. (R203)
Some medical Oncologists have their own limits for recommending AS. For example, some say no more than two positive cores, some think two should be the limit, whereas some believe that four cores out of 20 should be the limit.

3.1 All Treatments About Equally Effective for Low Grade PC
At our August support 2016 Group meeting, Dr. Anthony D’Amico predicted that we will hear some excellent news about prostate Cancer. On September 15, 2016 the NE Journal, and countless newspapers around the country reported that an English Study has concluded that men who have a low grade PC will do equally well if they have Surgery, Radiation or Active Surveillance (A/S), up to 10 years. The men were randomly assigned, and men on A/S were treated only if their cancer progressed.
I have read 6 different newspaper articles about this study, and not one doctor challenged the results of this conclusion. A few mentioned that if a man does A/S he must be tested for the remainder of his life, but omitted to mention that this is also true if the man was treated shortly after diagnosis, i.e., a recurrence.
The death rate for men who meet the criteria of A/S, and also the men treated shortly after diagnosis is the same at one percent, which is excellent. This includes men on A/S who never needed treatment and those who needed treatment and received it.
About 1/2 of the men in this study on A/S needed treatment within the 10 years.
If a man wants to further decrease his one percent probability of death he can select treatment, and a much higher probability of side effects. After 6 years some men in this study had side-effects from their treatment.
A consideration is that the trial has statistics for only ten (10) years, and that the results might be different when longer data is available, but for these results, men should have increased peace of mind.
The study does state that the cancer was more likely to progress and spread in the men on A/S than the treated men, but after the 10 years the one percent death rate included all three groups. As this test is continued, some men who were monitored now, MAY need treatment if they develop bone cancer because it is more frequent than in men who were treated at diagnosis.
The anxiety factor was about the same in all 3 groups and monitoring is crucial in all the groups.
Dr D’Amico said, “ Men do not need to fear they might die because they have not chosen the “right” course of treatment.
It is estimated that about 50% of men now opt for A/S.

Stan’s Comments:
Comment #1
In the English study the PSA was repeated “every 6 to 12 months after the first year” and that “an increase of at least 50% during the previous 12 months triggered a review”.
In the Boston area, and probably in the entire USA, the PSA test is repeated every 3 or 4 months for men doing A/S, and that a 20 or 25% increase would cause some concern and action.
Twelve months is an extremely long time interval. I call this Occasional Surveillance.
It is possible that the severity of any follow-on treatment after a 20- 25% PSA increase would occur sooner, and would be less severe than after a 50% or larger PSA increase. Active surveillance with closer monitoring than used in this study might result in better results for active surveillance, and might decrease the death rate.
In addition, because in this country two or three biopsies are also done while on A/S, any change might result in earlier treatment, improving the A/S outcomes.
Is it possible because so many men were on the A/S protocol in the English Study, they did not have the time, personnel or funds to test more frequently?
One doctor stated that monitoring in the UK study was not as vigilant as we do here although some argue we overdo it.
If a man wants to further decrease his one percent probability of death he can select treatment, and a much higher probability of side effects.

Comment #2
It is up to the Urologist to honestly present the benefits of A/S. They could drastically increase the number of men on A/S, but too many prefer not to for their own benefit. Dr. Otis Brawley, chief medical officer at the ACS said over 1,000,000 US men are getting needless treatment.

Comment #3
Men should tell anyone or family with pc to do not rush to judgement !
They should never be treated without consulting with all three pc specialists, especially the medical oncologists, and doctors who are active researchers.

The study can be found in the New England Journal of Medicine called:
10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer.

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4.0 Comment.
4.1 The Boston PC Support group has about 25 men who have been doing WW up to 13 years, and I know doctors who have dozens of patients who are doing WW for many years.

4.2 Percent of men who Stop WW to be Treated.
A July 2007 Johns Hopkins Letter had a graph indicating that 35 percent of men on WW came off the program and were treated for Curative Intervention. During the 14 years, seven (7) percent withdrew, two (2) percent died, four (4) percent lost to follow-up.
Stan’s comments: Note that only two percent died, which is probably no different than men with similar cases who were treated. Of the 35 percent who stopped the WW, and were treated, think of the many years they had without treatment, and its terrible side effects.


4.3-At diagnoses it is often impossible to determine if the cancer has already progressed to other parts of the body (Metastasized). Whether this man has immediate treatment or delays treatment, his cancer will worsen. The outcome in both cases will probably be the same. In fact the man on a Watchful Waiting Protocol will probably know sooner, because he is being closely monitored.

4.4- It is very rare that a doctor is sued because the condition of his patient on a Watchful Waiting Protocol , became worse. I never met a man suing because of this. Every man on WW must agree to do so, and is very closely monitored. It is my belief that doctors using this “being sued” excuse, are just trying to justify treating a man who is eligible for watchful waiting. This is just one of the excuse justifications for over treating / unnecessary treatment

4.5 Referring to Dr. Otis Brawley’s statement in paragraph 2.3, I say unnecessary treatment occurs because the prostate cancer medical profession stresses treatment, and discourages watchful waiting, and does not have a truthful conversation with their patients. A patient rarely sees a copy of the watchful waiting Criteria.
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5.0 References.
R128-National Cancer Institute |January 12, 2010, Volume 7 / Number 1 volume 7
R128A SOURCE: Journal of Urology, online August 18, 2010
R203-. Journal of the American Medical Association. 2007;298:1533-1538.
R208 J. Natl. Cancer Inst.2006;98:355-7
R214 British Journal of Cancer, 2009; DOI: 10.1038/sj.bjc.6605227
R226 Nov. 16 2009 10:29 News Staff
R228-Carol Ann Campbell may be reached at or (973) 392-4148. (6/22/2008)
R238- For information, contact Professor Pär Stattin, Department of Surgical and Perioperative Science, Division of Urology and Andrology, Umeå University, phone: +46 (0)90-785 2291
(R246A) J Clin Oncol 27. © 2009 by American Society of Clinical Oncology
R246B The European PRIAS Trial
R254-SOURCE: Journal of Urology, online August 18, 2010.
R341- Nov 30, 2010 (HealthDay News)
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April 25, 2013