Stage II Prostate Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Stage II prostate cancer is defined by the American Joint Committee on Cancer's TNM classification system:
- T1a-c, N0, M0, prostate-specific antigen (PSA) <20, Gleason 7.
- T1a-c, N0, M0, PSA ?10 <20, Gleason ?6.
- T2a, N0, M0, PSA ?10 <20, Gleason ?6.
- T2a, N0, M0, PSA <20, Gleason 7.
- T2b, N0, M0, PSA <20, Gleason ?7.
- T2b, N0, M0, PSA X, Gleason X.
- T2c, N0, M0, any PSA, any Gleason.
- T1-2, N0, M0, PSA ?20, any Gleason.
- T1-2, N0, M0, any PSA, Gleason ?8.
Radical prostatectomy, external-beam radiation therapy (EBRT), and interstitial implantation of radioisotopes are each employed in the treatment of stage II prostate cancer with apparently similar therapeutic effects. Radical prostatectomy and radiation therapy yield apparently similar survival rates with as many as 10 years of follow-up. For well-selected patients, radical prostatectomy can achieve 15-year survival comparable to an age-matched population without prostate cancer. Unfortunately, randomized comparative trials of these treatment methods with prolonged follow-up are lacking. Patients with a small palpable cancer (T2a, N0, M0) fare better than patients in whom the disease involves both lobes of the gland (T2c, N0, M0). Patients proven free of node metastases by pelvic lymphadenectomy fare better than patients in whom this staging procedure is not performed; however, this is the result of selection of patients who have a more favorable prognosis. Side effects of the various forms of therapy-including impotence, incontinence, and bowel injury-should be considered in determining the type of treatment to employ. (For more information on impotence, refer to the Sexuality and Reproductive Issues summary.)
In a retrospective pooled analysis, 828 men with clinically localized prostate cancer were managed by initial conservative therapy with subsequent hormone therapy given at the time of symptomatic disease progression. This study showed that the patients with well or moderately well differentiated tumors experienced a disease-specific survival of 87% at 10 years and that their overall survival (OS) closely approximated the expected survival among men of similar ages in the general population. The decision to treat should be made in the context of the patient's age, associated medical illnesses, and personal desires.
Radical prostatectomy has been compared to watchful waiting in men with early-stage disease (clinical stages T1b, T1c, or T2) in a randomized clinical trial performed in Sweden in the pre-PSA screening era.[3,4] Only about 5% of the men in the trial had been diagnosed by PSA screening. The estimated overall mortality difference after 12 years between the radical prostatectomy and watchful waiting arms of the study was not statistically significant: 32.7% versus 39.8%; P = 0.09; see Figure 1.[Level of evidence: 1iiA]