Natural History of Unscreened Detected Prostate Cancer

ABSTRACT & COMMENTARY

Synopsis: The 10-year disease-specific survival for Swedish men presenting with non-metastatic prostate cancer was 78%.

Source: Johansson JE, et al. JAMA 1997;277:467-471.

Screening and aggressive treatment for pros-tate cancer are widespread in the United States despite numerous uncertainties related to the disease’s natural history. Given these uncertainties, the cautious side of the debate highlights that it is possible that most men will die with prostate cancer, not from prostate cancer. Therefore, the aggressive treatment, usually radical prostatectomy, is generally overtreatment.

An earlier paper by Johannson of a population cohort of 223 men with initially untreated early prostate cancer found a low mortality rate after up to 10 years of follow-up.1 However, this report has been criticized due to its being only part of the full cohort. Therefore, in a recent report, Johannson et al describe the entire cohort of 642 consecutive, non-screened men with newly diagnosed prostate cancer between 1977 and 1984 in one Swedish county. When found, 84% had palpable tumors, 47% tumors confined to the gland, 28% locally advanced, and 25% metastatic disease. The mean age was 72 years. Only 6% had surgery or radiation therapy as their primary therapy.

Table

10-Year Survival Rates in Men with Prostate Cancer

Stage at Progressive Observed Corrected, Disease PresentatioFree Survival Survival Specific Survival

Without metastases 57% 33% 78%

Local disease 59% 37% 85%

Locally advanced 57% 25% 66%

Metastases 9% 5% 8%

The table shows representative survival results based on a minimum of 10 years and average of 14 years of follow-up. As expected, older patient age at diagnosis was associated with a better progressive-free survival. For example, 24% of men aged 61-70 developed metastases compared to 13% of men age 71-80.

COMMENT BY BRUCE E. HILLNER, MD

This study is very compelling evidence supporting the position not to screen for prostate cancer in men over age 70. In addition, for Caucasians, most cases of unscreened detected disease are found after age 70. Aggressive treatment, if used, should be restricted to men under 65-70 years old.

Reference

1. Johansson JE, et al. JAMA 1997;277:467-471.