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Ian McKellen (aka Gandalf the Grey) Using 'Waitful Watching' for Prostate Cancer

MedpageToday
Even the "the greatest spirit and the wisest" wizard sometimes has to deal with health issues.

Sir Ian McKellen
, 73, who has played the wizard in the Lord of the Rings Trilogy as well as the upcoming Hobbit series, told the UK's that he has had prostate cancer for 6 or 7 years:
"When you have got it you monitor it and you have to be careful it doesn’t spread. But if it is contained in the prostate it’s no big deal.

Many, many men die from it but it’s one of the cancers that is totally treatable so I have ‘waitful watching’. I am examined regularly and it’s just contained, it’s not spreading. I’ve not had any treatment."
Sir Ian's decision to forgo surgery or radiation treatment for his prostate cancer is one option many men don't realize they may have. According to the , "current estimates indicate that many more men are aggressively treated for prostate cancer than is necessary to save a life from the disease."

The option, termed active surveillance (AS), means closely watching for any sign that the cancer may be growing or changing. During active surveillance, a patient makes frequent doctor visits (typically every 3 to 6 months) along with a DRE (Digital Rectal Exam) and  test. After about a year, another prostate biopsy is done to check the cancer. If these tests show that the cancer is growing or changing in any way, radiation therapy or surgery is offered to treat the cancer.

Whether active surveillance is a reasonable option for a particular patient is dependent on several factors:
  1. Their age, symptoms, and general health
  2. The stage of the tumor




















3. The Gleason score (grade) of the tumor on a scale of 2 to 10. The Gleason score is based on microscopic tumor patterns assessed by a pathologist interpreting a biopsy specimen. It is a measurement of the degree of loss of the normal glandular tissue architecture.

The higher the Gleason score, the more aggressive the tumor is likely to act and the worse the patient’s prognosis. Most men with early-stage prostate cancer have a Gleason score of 6 or 7.

4.  The patient's
Based on these factors, a patient is assigned a particular risk for their cancer:












  • Low-risk prostate cancer is not likely to grow or spread for many years.
  • Medium-risk prostate cancer is not likely to grow or spread for a few years.
  • High-risk prostate cancer may grow or spread within a few years.
The ideal candidates for active surveillance have a low grade (Gleason 6 or less), low-risk prostate cancer that is small in size. The candidate may have concerns about complications of treatment affecting their potency or causing urinary symptoms.

AS may also be a good choice for older men with limited life expectancy, or for those dealing with other serious health conditions, such as heart disease or diabetes.

A number of studies have been looking at long term survival of patients using active surveillance. Laurence Klotz, MD, from Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada, and colleagues reported on their study in the January 2010 issue of the .  They followed 450 patients for a median follow-up of 6.8 years (range 1-13 years). Overall survival was 78.6%. The 10-year prostate cancer actuarial survival was 97.2%. Thirty percent of patients were reclassified over time as having a higher risk and were offered definitive therapy.

A similar study done by Jeffrey J. Tosoian, et. al at Johns Hopkins University (published in ) had similar results. About one-third of their patients underwent intervention 2.2 years (range, 0.6 to 10.2 years) after diagnosis. There were no prostate cancer deaths in either study.

In December 2011, a 14-member independent panel of the National Institutes of Health (NIH) that
"Active surveillance has emerged as a viable option that should be offered to patients with low-risk prostate cancer. More than 100,000 men a year diagnosed with prostate cancer in the United States are candidates for this approach."
But the panel also acknowledged that there are many challenges and unresolved issues, including:
  • Improvements in the accuracy and consistency of pathologic diagnosis of prostate cancer
  • Consensus on which men are the most appropriate candidates for active surveillance
  • The optimal protocol for active surveillance and the potential for individualizing the approach based on clinical and patient factors
  • Optimal ways to communicate the option of active surveillance to patients
  • Methods to assist patient decision-making
  • Reasons for acceptance or rejection of active surveillance as a treatment strategy
  • Short- and long-term outcomes of active surveillance
For more information, go to on Prostate Cancer