Dr. Donald S. Kaufman is a clinical professor of medicine at Harvard Medical School and director of the Claire and John Bertucci Center for Genitourinary Cancers at the Massachusetts General Hospital’s Cancer Center, where he has worked for 35 years.

Here's a transcript of his interview with NewsCenter 5 last Wednesday.

NC5: The traditional thinking and first impulse is that if we can catch cancer, we want to, right?

DK: I think it doesn't apply very well to prostate cancer.

NC5: Even at ages younger than 75?

DK: Even at younger ages. In the United States screening is done on most men over 50, and most educated men over 50 request a prostate specific antigen test (PSA). It turns out that prostate cancer is probably too common to want to find every case. Studies have been done on men with no PSA elevation, who are just part of a controlled group who had prostate biopsies done, and this is age 50-65 and 20 percent of those men with normal PSAs, no urinary symptoms, and nothing to suggest they have prostate cancer, were found to have prostate cancer. Now it turns out that many of those cancers would never reach a point with the individual at age 50 would be bothered by it. So you have to ask yourself, look, what this will do to my life, do I really want to know?

NC5: What you just said would surprise a lot of people.

DK: I agree.

NC5: Let me ask you about active surveillance. What do patients say when you tell them they might not need to do anything about their prostate cancer?

DK: I'm not advising against it, I'm advising some very careful reasoning to try to pick out those individuals who ought to have treatment from those who ought to have treatment because it's really quite foolish to say that a disease which kills thousands of men every year, and is the second biggest killer of men in the US, is a disease that doesn't need to be treated. That isn't the message at all. The question is, are there ways that we can look at people who have prostate cancer and decide who needs to be treated right away, who needs to be followed closely, and who doesn't need to be treated at all? We think we're beginning to make some headway into who needs treatment and who doesn't need treatment. That's the question.

NC5: What are the doctor and patient doing during active surveillance?

DK: First of all, we select patients very carefully for that, so it isn't anybody who's interested who's accepted. We have begun to use a formal program for entry into a surveillance program. We think it's a very serious step and it really isn't for everyone. There are men for whom it isn't appropriate psychologically -- the man who says, "I have cancer, I want it out." We understand that. Sometimes, if we don't think it's necessary for a given individual we will say so, but very often 30 minutes later the patient and his family say, "I like everything you've said. I want it out." We accept that.

NC5: Ultimately it's up to the patient?

DK: Of course. Or, to put it another way, it's absolutely critical that the patient be comfortable with not being treated. We don't try to persuade every patient not to be treated, but if we can't reason with a patient and a patient's family and come out with a sense that that patient, that family will sleep at night, every night, then we don't think it's a good idea. But we do think we're learning how to identify patients who don't necessarily need treatments.

NC5: When a patient is under 'active surveillance' how often are you doing blood tests, exams?

DK: Surveillance consists of a PSA test every six months, digital rectal examinations at the same time, every six months, and a second biopsy about 12-18 months after the first biopsy which led to the diagnosis being made. And the reason for the second biopsy is very poorly understood by most patients. The reason for the second biopsy in the mind of most patients is to see if the disease is progressing, so patients often think they will have one every year. But with active surveillance we don't recommend a biopsy annually. We recommend a second biopsy at 12-18 months and the reason for that is to see if there was a sampling error in the first biopsy. If the PSA or the rectal examination hint at change, we don't say to the patient, "well, we've already decided on surveillance." Surveillance would end, and what makes surveillance viable is that it's not forever. And it turns out that if you look at patients with fairly mild cancers, and they are observed in the manner I just said, and you look at those patients 10 years later, there are no deaths from prostate cancer in that group.

NC5: What are they not having to go through by choosing active surveillance if that's the best route for them?

DK: They're gaining a huge amount. Whatever treatment is given for prostate cancer is very, very disabling. There's nothing easy about it. Radiation treatment, never mind the fact that it takes 8 1/2 weeks of Monday-through-Friday treatment, which is an inconvenience, but it also has at least a 40 to 50 percent chance of causing impotence. Incontinence is actually very unlikely with radiation, but radiation given in that manner can cause rectal bleeding for 2-3 years, or for a decade. It's not serious but it makes patients worry that something else is going on in the colon. So it's a very big quality of life issue. There's urinary urgency and other symptoms, so there's nothing easy about treatment, surgical treatment likewise. Surgery has an incidence of incontinence, diaper-requiring incontinence, that may be as high as, in national figures, 15 to 20 percent. In the hands of very experienced urologists, maybe 4 or 5 percent, but it still occurs. The problem with prostate cancer treatment is that we deal with individuals who have very mild disease, but there's no mild treatment. There's just one flavor of treatment and it's highly aggressive. So there's no easy treatment for what ought to be a very early disease, and that's where active surveillance comes in.

NC5: Do you think that approach should be applied to other cancers? Why is prostate cancer unique in this sense?

DK: I do not think it should be applied to other cancers. I think prostate cancer is unique in the indolent way in which it moves. We did PSA testing beginning in 1989. Before that, cancer of the prostate was found only when it was causing symptoms such as metastatic disease, bone and back pain. The PSA led us to make the diagnosis probably, on the average, eight to nine years earlier, so there's a lead time. There's no lead time for colon cancer or breast cancer. The thing about prostate cancer and the reason we talk to patients so much about active surveillance is that there's a lot of years that go by that aren't really critically important to the patient. So I don't claim expertise on other cancers. I don't recommend this approach because prostate cancer is unique.

NC5: What percentage of your patients right now are using active surveillance?

DK: 25 to 30 percent.

NC5: How does that compare to five or 10 years ago?

DK: In our clinic five years ago, it was 5 percent. There has been a huge increased interest in this at MGH Cancer Center because we think we have the data to support the no-treatment option. Because it doesn't mean no treatment, it means no treatment right now. And we're ready to make that change.

NC5: Are you involved in some of those clinical trials to determine which treatments might best help specific patients? How long do you think it will be until you have results, or are you constantly fine tuning?

DK: I think we're constantly fine tuning, but some of the things that we really need to learn are probably more than five years away. To give you one example, there is work being done at MGH Cancer Center to look at gene arrays, patients with Gleason (grade) 6, the most favorable grade of prostate cancer, and try to figure out which of those patients with Gleason (grade) 6 disease are destined to have no trouble ever, and which of them are the bad actors. We need more precise information than digital examinations, PSAs, etc. And some work being done at MGH is designed to provide answers to that, but it's still pretty early. It actually moves us if a patient's father or brother had prostate cancer. It's not just a detail. We don't quite know how to quantitate it, but it actually turns out to be something which moves us away from surveillance recommendations. The other thing, of course, that moves us toward surveillance, is so many patients who have other medical illnesses that leaves them with an expected lifespan of less than 10 years. Such patients should not be treated for prostate cancer. And we don't even consider that surveillance. That's a decision not to treat based on good common sense.

NC5: One thing Mr. Rubin talked about is the team approach. You have doctors from varying specialties all in one room together, not having talked before hand. Talk to me about that, and also about critics of active surveillance.

DK: I think most people really respect it. The old battle lines of surgeons recommending surgery always, and radiologists recommending radiology and medical people like me being, what do we say, objective, so we have the right answer. That washes away in our group and that's what been so exciting about it. What we do is recognize that prostate cancer can be cured by surgery or by radiation, one or the other. They're equally effective, and how does a patient decide? So we see a lot of patients in our multidisciplinary center where they saw a surgeon on Tuesday and a radiologist on Thursday and they come out with, "Decide what you want; it's your decision." And it's not unusual for those patients to want to come to this place because they've heard about a clinic where the doctors are all in the room at the same time and we don't agree on everything before we enter the room. We try to have a discussion in the room and if we disagree, which happens fairly often, the disagreement is aired in front of the patient and the family. We always include the family.

NC5: And that helps inform their decision.

DK: Yes, it helps to inform their decision and I find it fascinating because patients are so appreciative of this approach. Sometimes when we're almost finished with the discussion and they've heard a balanced discussion about surgery or radiation or surveillance, it almost comes out that they conclude that we're going to send them out and say, "Here are the three possibilities, think it over." Patients don't like that. It is their decision but they really want to find out what we think. What I find so exciting about this is that we have surgeons who recommend radiation and radiation oncologists who recommend surgery and we give the reasons. We actually try very hard to remind the patient that it's the patient's decision and then give them our view as to what makes sense. More often than not, despite the disagreements that take place, we end up having a consensus. The biggest problem with this clinic is that it's wickedly inefficient and the hospital has said that's all right. We think it's really great. We could see many more patients alone that we could together, but we think it's important.

NC5: Talking about the genetic tests made me wonder; is there any lead on a prostate cancer gene?

DK: There are no leads that we can talk about right now.