Rich Dietman: Welcome to Mayo Clinic podcast. Our topic today is watchful waiting and what it means for a person with cancer. I'm your host, Rich Dietman.

In today's podcast, we're talking about watchful waiting, an approach to managing and monitoring some cancers. My guest is Mayo Clinic cancer specialist Dr. Tim Moynihan. Dr. Moynihan practices in the Department of Medical Oncology at Mayo, and he's also cancer medical editor for MayoClinic.com. Dr. Moynihan, thanks for being with us.

Dr. Moynihan: Thank you for having me.

Rich Dietman: Just what exactly is meant by the term "watchful waiting"?

Dr. Moynihan: What we do with watchful waiting is in some people with certain types of cancers that may behave in a relatively indolent, or slow-growing, fashion, it may be reasonable to just watch and see what happens to the cancer before doing anything with it, because sometimes the cancer itself may not grow very fast, and it's less harmful to the patient if we just watch it for a while and get an idea of what it's doing. In many situations it can be a very safe thing to do, although people, I understand, are very reluctant to leave a cancer in their body and not do something about it. There are situations where it is possible that the cancer may never bother them in their lifetime, depending on the overall health of the patient, the age, other conditions that they have and the type of cancer. So sometimes just watching for a period of time makes a lot of sense.

Rich Dietman: Watchful waiting is often used with some stages or some types of prostate cancer. Talk about how it's used specifically in those cases.

Dr. Moynihan: Exactly. In some men who are found to have prostate cancer, particularly if it's a less aggressive form of cancer, for example, a lower Gleason Score, and in somebody who perhaps may be of a more advanced age or again with significant other health problems, it may be that the cancer even if left alone will never cause that individual a problem, and their other medical conditions or their general age and other health may dictate the course of their life. So if we intervene on all of those people, we run the risk of giving them side effects without really helping their overall condition. So prostate cancer is where we use watchful waiting probably more than any other disease, and it may be appropriate in very selective cases.

Rich Dietman: Are there other cancers where watchful waiting is sometimes used?

Dr. Moynihan:  Sometimes, particularly in things like chronic lymphocytic leukemia and a few other situations, especially given the age and the general condition of the individual patient. Some women who are at an advanced age and have other medical problems, a breast tumor may be reasonable to watch it for a while, especially if it's found at a very early stage, intervening before it becomes a problem, but maybe delaying the intervention to see how the other medical conditions go first.

Rich Dietman: So if my doctor suggests watchful waiting for prostate cancer, it doesn't necessarily mean that there just aren't any good treatments available.

Dr. Moynihan: No, not necessarily. What we're trying to do is weigh what benefits the treatments do versus what harm not treating does. So many of our treatments do have side effects, and if the cancer wouldn't bother you anyway, is it worth putting up with those side effects? What we have to be careful about is we don't want an aggressive cancer to go because, of course, the cancer can cause problems: It can spread. It can cause pain. It can cause organ dysfunction. It can cause death. We don't want that to happen. But there are people who have a more indolent form of cancer where no matter how long we leave it there, the cancer won't bother them.

Rich Dietman: How will my doctor and I know when it's time to shift from watchful waiting to another treatment approach?

Dr. Moynihan: First of all, how does a person feel? And is the cancer causing them to feel poorly in any way? Whether it be a pain, for example, in prostate cancer difficulty passing their urine or some other problem that it's giving them. If it's giving them a problem, then it's very much worth treating it. The other thing is, how rapidly is the cancer itself changing? So we should keep an eye on the cancer. And it may be through a blood test. It may be through a physical exam. It may be through some other way. If it's changing only very, very slowly and unlikely to give the patient problems, we tend not to intervene. If it begins to change more rapidly and tells us this may cause a problem in the near future, then we should intervene sooner. For example, in the example you cited earlier, in prostate cancer we watch the PSA, and we often look for what's called the PSA doubling time. How long of a time does it take for the PSA number to double? We noted that in those patients whose PSA number doubles in less than six months time, they have a more rapidly aggressive cancer that's more likely to give them trouble in the near future. So if we see it start to rise rapidly like that, we may want to intervene sooner than later. If on the other hand the number goes up very slowly, and it does this in quite a few individuals, then treating may just give side effects without influencing the course of the cancer itself.

Rich Dietman: It sounds that, in general, watchful waiting is used earlier on than later in a cancer. Is that true?

Dr. Moynihan: I would say for the most part that's probably true, but again it's specific to the individual and the other health conditions that person has. For example, somebody at a very, very advanced age who has a bad heart or bad kidneys or other problems, may well be worth just watching in that setting so that we don't cause any additional harm for them through any of our treatments. And, quite frankly, some of those people who have these other severe medical conditions, those other medical conditions may take their life before the cancer has a chance to do any harm to them.

Rich Dietman: Earlier on you alluded to the anxiety and worry that could come with living with a cancer that's not being treated. How do you advise your patients to handle that assuming they elect to do watchful waiting?

Dr. Moynihan: It's a very difficult thing because you're waiting for something bad to happen, and it's a very difficult thing to be able to do that. So this is not right for everybody. For some people who can't handle that anxiety, it may be worth the side effects of treatment to try and approach the cancer. For other patients who can deal with this, you have to trust your doctor, talk to them and understand that as long as we monitor appropriately, we can hopefully intervene before it actually causes a problem, and thereby, if it's not going to cause a problem, again avoid side effects of too early a treatment. If it does start to change, then prompt intervention is probably called for. So if you're having difficulty with it, the anxiety of the approach of watchful waiting, if you're not comfortable with that idea, this is where it's maybe a good idea to get a second opinion from another physician. If both physicians agree that watchful waiting is appropriate in your setting, maybe that would be a very reasonable approach.

Rich Dietman: Thanks very much Dr. Moynihan. We've been talking about watchful waiting as it relates to managing some cancers with Dr. Tim Moynihan, a cancer specialist at Mayo Clinic and cancer medical editor for MayoClinic.com. You've been listening to Mayo Clinic podcast. I'm Rich Dietman.

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