Prostate cancer mortality

Prostate Cancer Indolent in Early Stage, More Aggressive Later

Early-stage prostate cancer has an indolent course but becomes more aggressive after about 15 years, according to the results of a long-term cohort study published in the June 9 issue of JAMA. The investigators recommend earlier radical treatment, whereas the editorialists are more conservative and recommend waiting for results of ongoing long-term intervention trials.

“Without understanding the natural history of prostate cancer diagnosed at an early, localized stage, patient counseling and clinical management are difficult. The challenge is to maximize the possibilities for survival without extensive overtreatment,” write Jan-Erik Johansson, MD, PhD, from Orebro University Hospital in Sweden, and colleagues. “Even without initial treatment, only a small proportion of all patients with cancer diagnosed at an early clinical stage die from prostate cancer within 10 to 15 years following diagnosis…. However, little is known about disease progression and risk of death beyond 10 to 15 years of watchful waiting.”

Of 223 consecutive patients from central Sweden with early-stage, initially untreated prostate cancer who were observed for a mean period of 21 years, 49 patients were still alive at 15 years, and 39 patients (17%) had generalized disease during complete follow-up. At enrollment, classification was T0-T2 NX M0. Symptomatic patients with tumor progression underwent orchiectomy or estrogen treatment.

Although most cancers had an indolent course during the first 10 to 15 years, the course became more aggressive from 15 to 20 years. During that time, there was a substantial decrease in cumulative progression-free survival (from 45.0% to 36.0%), survival without metastases (from 76.9% to 51.2%), prostate cancer–specific survival (from 78.7% to 54.4%), and prostate cancer mortality rate (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 (P = .01).

This study adds to our understanding of the natural history of prostate cancer. It does not answer the question that continues to plague physicians and patients – how should we best manage early prostate cancer.

We have ongoing studies which are comparing aggressive management and watchful waiting. This article does not (in my opinion) invalidate the goals of that study.

Certainly, as patients get older (with lower life expectancy), the urgency of aggressively treating early prostate cancer decreases. Hopefully, we will gain more information that will allow us to best understand when to convert from watchful waiting to aggressive therapy for younger patients.