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Prostate Cancer with Bone Metastases at Presentation: Current Patterns of Care and Outcomes
Abstract & Commentary
By William B. Ershler, MD, Editor, INOVA Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, DC.
Synopsis: Using the CaPSURE registry, clinical features and prognostic factors were identified for the small percentage of patients who have bony metastases at the time of initial presentation. Although a protracted course (greater than five years) is expected, the presence of comorbidities and younger age were both found to have significant negative impact on survival.
Source: Ryan CJ, et al. Initial treatment patterns and outcome of contemporary prostate cancer patients with bone metastases at initial presentation. Data from CaPSURE. Cancer. 2007;110:81-86.
Currently, the great majority of patients with prostate cancer are diagnosed with clinically localized disease. The unique features of those that present with bony metastatic disease are the subject of the report from Ryan and colleagues. The investigators examined the CaPSURE registry which is derived from the practices of 40 primarily community-based urologists across the country. The CaPSURE program1, 2 does not include interventional trials and serves to describe community patterns of practice. Clinical data including laboratory results, pathology findings and treatments are provided by the participating physician. Additionally, information regarding comorbidities is collected by self-report questionnaire at the time of enrollment.
Of the 10,186 patients diagnosed and enrolled in CaPSURE between 1990 and 2003, 284 (2.4%) had bony metastases at the time of initial presentation, but data for seven of these were unavailable, resulting in a study population of 277 men. After a median follow-up of 3.8 years, 107 patients (39%) died. Of these, 68 (64%) died of cause related to prostate cancer. The 5-year survival of all patients was 71% and the median survival had not been reached at the time of last follow-up. Approximately 84% received some form of hormonal therapy. Prostate cancer-specific mortality was found to be correlated with the presence of comorbid illness, younger age at diagnosis, and a Gleason score of >7 in the primary tumor.
CaPSURE provides a unique data set from which community standards can be observed. The low incidence of bony metastases at the time of diagnosis (2.4%) reflects a general pattern of earlier diagnosis reported earlier.3 Such may well be the result of increased public awareness and widespread utilization of prostate-specific antigen (PSA) testing. The great majority (85%) of men diagnosed with bony metastases at the time of initial presentation were treated with some form of androgen-deprivation therapy (LHRH agonist/antagonist or orchiectomy). Yet, it was surprising to see that 17% underwent some form of local therapy (eg, radical prostatectomy).
The analysis also revealed two findings of interest. The first relates to the influence of comorbidities, which increased both the rate of all-cause mortality as well as prostate-specific mortality. This is analogous to observations throughout the geriatric medicine literature on the influence of comorbidities on overall survival, but also to breast cancer in which the number of comorbidities directly relate to survival.4,5 The other is the inverse correlation between age and risk of death due to prostate cancer. Again, the seeming paradox that younger patients who present with metastatic disease are more likely to have an aggressive course and succumb to their disease when compared to older patients with similar presentation is analogous to the situation with breast cancer in which younger patients are frequently found to have more aggressive disease.6 Although, as the authors suggest, younger patients are more likely to die of the prostate cancer because there are less competing causes (ie, less comorbidities), there is now sufficient experimental data suggesting certain cancers exhibit less aggressive growth and spread in older hosts. Prostate cancer, hormonally-dependent like breast cancer, would seem to fit this category.
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2. Lubeck DP, et al. Urology. 1996;48(5):773-777.
3. Ryan CJ, et al. Urol Oncol. 2006;24(5):396-402.
4. Yancik R, et al. Jama. 2001;285(7):885-892.
5. Satariano WA, Ragland DR. Ann Intern Med. 1994;120(2):104-110.
6. Balducci L, Ershler WB. Nat Rev Cancer. 2005;5(8):655-662.