Active surveillance should be the preferred option for men diagnosed with low-grade prostate cancer who currently qualify for this protocol. Avoiding early treatment will prevent unnecessary treatments and their side effects. This said, it is important to recognize that even early stages of prostate cancer, if given enough time, could progress to more aggressive forms and become more difficult to treat.
Conservative treatment of prostate cancer has a long natural history. This history was written years before the advent of the PSA era, and the best-documented details of that history exist in the data compiled by the Scandinavian cancer registries and the studies of those data.
What do we mean by conservative treatment? To all intents and purposes, conservative treatment of prostate cancer meant that nothing was done until a man showed clear symptoms of prostate cancer. If a man had no symptoms, nothing was done. When a man showed symptoms (urinary retention, bone pain, etc.), these symptoms would be treated (“palliated”) so that the patient would have the best possible quality of life, but treatment was not carried out with curative intent.
For the most part, between 1970 and 1990, this is how prostate cancer was treated in Scandinavia, where excellent long-term health records are available going back decades. By looking at what happened to these men with conservatively treated prostate cancer, we can understand how the disease progresses when it is effectively undisturbed (untreated) until late in its course.
So let’s look at the available data, complied over the years in seven major Scandinavian analyses:
In 1994, Grönberg et al. reported that patient age alone could be a significant prognostic factor in prostate cancer. They analyzed data from a large and unselected cohort of 6,890 prostate cancer patients diagnosed between 1971 and 1987 in northern Sweden. Tumor grade information showed that 26.4 percent of the patients had well-differentiated tumors (grade 1), 40.0 percent had moderately differentiated tumors (grade 2), and 17.7 percent had poorly differentiated tumors (grade 3). There were no data to suggest that tumors in younger patients are more aggressive per se. However, loss of life expectancy differed significantly among all age classes and in all three grades. In patients with grade 1 tumors the time lost due to prostate cancer ranged from 11.0 years in the youngest age group to 1.2 years in oldest age stratum, even though the relative survival was approximately 0.70 in all age classes.
In 1996, Adolfsson published data on 172 Swedish patients diagnosed with T1-3NxM0 prostate cancer. These patients were all diagnosed between 1978 and 1982 and followed for at least 10 years using a surveillance protocol with deferred treatment on symptomatic progression. The median age at diagnosis was 68 years. The disease-specific survival at 10 years was 80 percent for the total series, 84 percent for the subgroup with T1-2 tumors, and 92 percent for patients with T1-2 tumors diagnosed when the patients were less than 70 years of age. For the subgroup with T3 tumors, the disease-specific survival at 9 years was 70 percent. In all subgroups the competing mortality was higher than the prostate cancer mortality.
In 1997, Johansson et al. published the results of a population-based study of 642 patients in Orebro, Sweden, with prostate cancer of any stage. The patients were consecutively diagnosed between 1977 and 1984, had an average age of 72 years, and were followed until 1994. Prostate cancer accounted for 201 of all 541 deaths (37 percent). Among 300 patients initially diagnosed with localized disease (T0-2), 33 (11 percent) died of prostate cancer. The corrected 15-year survival rate of 81 percent among these 300 patients was similar in 223 patients who had deferred treatment and in 77 who received initial treatment. The corrected 15-year survival was 57 percent in 183 patients initially diagnosed with locally advanced cancer (T3-4) and 6 percent in the 159 patients who had distant metastases at the time of diagnosis.
Also in 1997, Grönberg et al. published data from a study population of 6,514 patients diagnosed with prostate cancer between 1971 and 1987 in northern Sweden. about 85 percent of these patients died during the follow-up period, and the prostate cancer-specific mortality was estimated to be 55 percent. Age at diagnosis was found to be a strong predictor of prostate cancer death. Patients diagnosed before the age of 60 had an 80 percent risk of dying of prostate cancer, whereas those over 80 years of age at diagnosis had less than a 50 percent risk of prostate cancer-related death.
In 1999, Adolfsson et al. published a report on a prospective study of long-term survival in 50 selected men with locally advanced, non-metastatic prostate cancer managed with deferred treatment. The men were treated if and when symptoms occurred or upon their request. All patients were followed until December 1994, and no patient was lost to follow-up. The median patient age at diagnosis was 71 years. All patients were followed for at least 144 months or died before then. Actual overall survival rates at 5, 10, and 12 years were 68, 34, and 26 percent; disease-specific survival rates were 90, 74, and 70 percent, respectively. A third of the patients had received no cancer-specific treatment at follow-up or before death.
In 2004, Johansson et al. published additional data on the 223 men from the original Orebro study (see above) who had received deferred treatment. By this time, this patient cohort had then been followed for an average observation period of 21 years. The patients who had had tumor progression were treated hormonally (either by orchiectomy or with estrogens) if they had symptoms. After complete follow-up, 39/223 patients (17 percent) experienced generalized disease. Most cancers had an indolent course during the first 10 to 15 years. However, further follow-up from 15 years (when 49 patients were still alive) to 20 years revealed a substantial decrease in cumulative progression-free survival (from 45.0 to 36.0 percent), survival without metastases (from 76.9 to 51.2 percent), and prostate cancer-specific survival (from 78.7 to 54.4 percent). The prostate cancer mortality rate increased from 15 per 1,000 person-years during the first 15 years to 44 per 1,000 person-years beyond 15 years of follow-up.
While there is considerable variation in the results of these seven studies, several things seem to be very clear:
· Early stage, low and intermediate grade disease can be treated successfully with conservative therapy in older men with at least 10 and perhaps 15 years of life expectancy.
· More aggressive prostate cancer results in a high rate of mortality when left untreated.
· Age is an important factor in decision-making.
· If early disease is diagnosed at a young age, there is a high risk of the patient dying from prostate cancer if treated conservatively.
There has been resistance to accept active surveillance in the urology practice, but the door has been opened for men to learn and recognize this possibility if their cases qualify. As survivors with knowledge we need to advocate and support this modality for the benefit of those that follow our footsteps.
Surviving prostate cancer since 1992. RP; Orchiectomy;
GS (4 + 2); bilateral seminal vesicle invasion; tumor attached to rectal wall. Last PSA September, 2010: <0.1 ng/ml
Laughter is the best medicine!