Most Prostate Cancer Does Not Need Initial Treatment
Abstract & Commentary
By Joseph E. Scherger, MD, MPH, Clinical Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study.
Synopsis: A decision analysis shows that active surveillance is a good option for men age 65 and older with low-risk prostate cancer (Gleason score of 6 or less). Active surveillance results in the highest quality-of-life scores compared with different treatment options, and 61% of these men will go on to treatment after a median of 8.5 years, with a slight increased mortality risk. Only 10% of men currently receive active surveillance for low-risk prostate cancer.
Source: Hayes JH, et al. Active surveillance compared with initial treatment for men with low risk prostate cancer: A decision analysis. JAMA 2010;304:2372-2380.
A study team from harvard and the university of California, San Diego, conducted a decision analysis of the current literature to compare active surveillance with three initial treatment options for men age 65 or older with low-risk localized prostate cancer by biopsy (Gleason score 6 or less). Active surveillance is defined as regular physical examinations, PSA measurement, and rebiopsy 1 year following diagnosis and every 3 years thereafter. Treatment is triggered by progression to a Gleason score of 7 or higher, other evidence of disease progression such as a rapid rise in PSA, or patient preference.
Active surveillance was compared with initial brachytherapy, intensity-modulated radiation therapy (IMRT), and radical prostatectomy. Probabilities of complications and mortality were calculated from previous studies. The relative risk of death from initial treatment compared with active surveillance was 0.83, or 9% compared with 11%. Complications of treatment include impotence, urinary incontinence, bowel problems, or a combination of these, and most men get at least one of these from treatment. Sixty-one percent of patients choosing active surveillance went on to treatment after a median of 8.5 years, and the quality adjusted life-years was better in this group by 6 months compared with brachytherapy, the most effective initial treatment.
Men choosing active surveillance do not have any evidence of increased anxiety over time compared with men undergoing treatment.
In 2009, 192,000 men in the United States were diagnosed with prostate cancer, and the death rate is about 22,000. Seventy percent of men diagnosed with cancer have localized low-risk disease (Gleason score of 6 or less). Currently more than 90% of these men undergo treatment after diagnosis, and the majority experience at least one adverse effect. This analysis based on the current literature suggests that up to 60% of these men could choose active surveillance with a higher quality of life and a small risk of not pursuing initial treatment. Only 10% of men currently choose this option.
This study has reframed my approach to low-risk localized prostate cancer, particularly in men 65 and older. It is important to remember that there are two general types of prostate cancer. Younger men, age 40-60, who get prostate cancer often have a very aggressive disease that commonly defies treatment and has high mortality. Older men more often have a more benign type of cancer. Most of us already consider prostate cancer in men age 80 and older as something that most likely the patient will not suffer from or die of. Cancer in men age 65 is a different matter.
I have already summarized this study with patients in this situation, and found them very open to active surveillance when they realize that it is not a foolish decision. Many men do not seek treatment to an area involved with their sex life and with urination. What I like about the term and definition of active surveillance is that it does not imply "forget about it and take your chances." Close attention is given to the cancer and more than half of the men will eventually undergo treatment.
This study is a simulation model using the current research evidence. Obviously, this will change with more research. I hope this study gives us many more men who choose active surveillance so that we will have a large cohort of real men on which to base our evidence in guiding patients.