Prostate Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Treatment Option Overview for Prostate Cancer
Table 9. Treatment Options by Stage for Prostate Cancer continued...
Patient selection, testing intervals, and specific tests, as well as criteria for intervention, are arbitrary and not established in controlled trials.
In the United States, as in other settings with widespread PSA screening, the results of conservative management of localized prostate cancer are particularly favorable. Many men with screen-detected prostate cancer are candidates for active surveillance, with definitive therapy reserved for signs of tumor progression.
Evidence (watchful waiting or active surveillance):
- A population-based study with 15 years of follow-up (mean observation time = 12.5 years) has shown excellent survival without any treatment in patients with well-differentiated tumors or moderately well-differentiated tumors clinically confined to the prostate, irrespective of age.
- Tumor was not detected in any of these men by PSA screening, since PSA was not available at the time.
- The patient cohort was followed for a mean of 21 years after initial diagnosis. The risk of prostate cancer progression and prostate cancer death persisted throughout the follow-up period.
- By the end of follow-up, 91% of the cohort had died; 16% had died of prostate cancer.
- A second, smaller population-based study of 94 patients with clinically localized prostate cancer managed by a watch-and-wait strategy had very similar results at 4 to 9 years of follow-up.
- In a selected series of 50 Jewett stage C patients, 48 of whom had well-differentiated tumors or moderately well-differentiated tumors, the prostate cancer-specific survival rate at 5 years was 88% and, at 9 years, the rate was 70%.
- In a population-based Surveillance, Epidemiology and End Results (SEER) Medicare-linked database, 14,516 men with localized prostate cancer (T1 or T2 cancer) diagnosed from 1992 to 2002 were followed on conservative management (no surgery or radiation for at least 6 months) for a median of 8.3 years. The median age at diagnosis was 78 years.[Levels of evidence: 3iA, 3iB]
- At 10 years, the prostate cancer-specific mortality rates were 8.3% for men with well-differentiated tumors, 9.1% for men with moderately well-differentiated tumors, and 25.6% for men with poorly differentiated tumors.
- Corresponding risks of dying of other causes were 59.8%, 57.2%, and 56.6%, respectively.
- 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 years 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).[Levels of evidence: 3iA, 3iB]
- 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% in the prostatectomy group and 3.3% in the radiation therapy group).
- The 10-year risk of dying from causes other than prostate cancer was 19.2% in the surveillance group versus 10.2% in the curative intent group, showing evidence of selection of patients who were not as healthy for surveillance on average.
- Tumor pathologic 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 with 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 group 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 the assignment of higher tumor grades.
- A retrospective analysis of outcomes of men with prostate cancer demonstrated a 10-year disease-specific survival rate of 94% for expectant management for Gleason score 2 to 4 tumors and 75% for Gleason score 5 to 7 tumors; this is similar to a previous study using the SEER database with survival rates of 93% and 77%, respectively.
- In a retrospective analysis from the European Randomized Study of Screening for Prostate Cancer (ERSPC), 616 men (mean age 66.3 years) diagnosed with prostate cancer in the screening arm met criteria for active surveillance that included PSA (≤10 ng/ml). PSA density (<0.2 ng/ml), tumor stage T1c/T2, Gleason score (≤3 + 3 = 6), or two or more positive biopsy cores.[Level of evidence: 3iiB]
- With a median follow-up of 3.91 years, the 10-year prostate cancer-specific survival rate was 100%. By 7.75 years, 50% of men had received active treatment (but 55.8% of these men received treatment despite continued favorable PSA and PSA-doubling time). The overall survival (OS) rate at 10 years was 77%.