In the United States, as in other settings with widespread PSA screening, the results of conservative management of localized prostate cancer are particularly favorable. In a population-based Surveillance, Epidemiology and End Results (SEER) Medicare-linked database, 14,516 men with localized prostate cancer (T1 or T2 prostate cancer) who were diagnosed from 1992 to 2002 were followed while undergoing conservative management (i.e., no surgery or radiation for at least 6 months) for a median of 8.3 years. The median age at diagnosis was 78 years. At 10 years, the prostate cancer-specific mortality rates were 8.3%, 9.1%, and 25.6% for men with well-differentiated, moderately differentiated, and poorly differentiated tumors, respectively. Corresponding risks of dying of other causes were 59.8%, 57.2%, and 56.6%.[Levels of evidence: 3iA, 3iB]
Another population-based observational study of men with clinically localized prostate cancer diagnosed in the PSA-screening era has also been reported, with a median follow-up of 8.2 years. A nationwide Swedish cohort of 6,849 men aged 70 or younger with T1 or T2 prostate cancer, Gleason scores of 7 or lower, and serum PSA levels of lower than 20 ng/mL was followed after an initial strategy of surveillance (N = 2,021), radical prostatectomy (N = 3,399), or radiation therapy (N = 1,429). The cumulative risk of prostate cancer-specific death at 10 years was 3.6% in the initial surveillance group and 2.7% in the curative intent groups (i.e., 2.4% and 3.3% in the prostatectomy and radiation therapy groups, respectively). The 10-year risk of dying from non-prostate-cancer causes was 19.2% in the surveillance group versus 10.2% in the curative intent group, respectively, showing evidence of selection of less healthy patients for surveillance on average.[Levels of evidence: 3iA, 3iB]
Tumor pathological characteristics of 222 men in that cohort who followed an initial strategy of surveillance but underwent deferred prostatectomy at a median of 19.2 months (10th -90th percentile, 9.2-45.5 months) were compared to those who underwent immediate prostatectomy. There were no differences between the groups in extraprostatic extension or tumor margin positivity. Although the Gleason scores at radical prostatectomy were higher in the surveillance groups than in the immediate prostatectomy group, this occurred concurrently with a national training effort in prostate tumor pathology evaluation that led to the upgrading of tumor specimens. Therefore, the investigators concluded that the delay in prostatectomy in the surveillance group artifactually led to assignment of higher tumor grades.
Many men with screen-detected prostate cancer are candidates for active surveillance, with definitive therapy reserved for signs of tumor progression. In a retrospective analysis from four of the centers of the European Randomized Study of Screening for Prostate Cancer (ERSPC), 616 men (mean age 66.3 years) in the screening arm represented between 27% and 38% of the men diagnosed with prostate cancer in the trial. The 616 men met the following criteria for active surveillance:
- PSA ?10 ng/mL.
- PSA density <0.2 ng/mL.
- Tumor stage T1c/T2.
- Gleason score ?3 + 3 = 6.
- ?2 positive biopsy cores.