Tumor grade, treatment, and relative survival: a cohort analysis


Sweden’s National Prostate Cancer Register now contains detailed information on tens of thousands of men diagnosed with prostate cancer.

Ladjevardi et al. used the data from this registry to evaluate the survival of men with potentially curable prostate cancer with respect to their Gleason score (GS) and their treatment, as practiced in the community at large. They assessed the ratio of deaths observed in the prostate cancer patients to deaths expected in the general male Swedish population of the same age.

Patients were included in the analysis if they were < 75 years of age. Potentially curable prostate cancer was defined, for the purposes of this study as having:

  • Clinical stage cT1 to cT3, N0 or Nx, and M0 or Mx
  • PSA < 20 ng/ml

The results of this study are as follows:

  • The authors used the national register to identify 31,903 men with potentially curable prostrate cancer, as defined above.
  • Gleason score data were available for 28,454 of these men.
  • 19,606 of the men for whom Gleason scores were available (60.8 percent) were treated with curative intent.
  • 12,645 of these men (39.2 percent) were given hormonal treatment or expectant management.
  • There was a significantly greater survival benefit compared to the expected survival from treatment with curative intent among men with high-grade tumors.

The authors note that the results of this study have to be interpreted with some caution, as there was no randomization between the treatment groups. However, with that proviso, they state that:

  • The  survival for men with well-differentiated (relatively low grade) tumors is close to that of the general population, regardless of treatment.
  • Survival times are “dismal” for men with poorly differentiated (relatively high grade)  tumors, whatever treatment is applied.
  • Nevertheless, men with poorly differentiated tumors benefit more from curative treatment than do men with well-differentiated tumors.

These data, even though they need to be “interpreted with some caution” (as advised by the authors) appear to add additional evidence to the value of active surveillance as a management strategy for men with low grade, low risk, early stage prostate cancer compared to active intervention. However, the data also seem to suggest that available treatment strategies are of limited value in men with higher grade and higher risk disease.

Perhaps we need to become more acceptant of the fact that current initial treatments of many men with high grade, high risk disease are little more than palliative, and are commonly not capable of eliminating their cancer, even though such treatments may help to delay disease progression.

If this is the case, then Whitmore’s conundrum is alive and well — for all the efforts of the past 20+ years.

One Response

  1. Indeed Whitmore got it right. What a pity his wise views are accepted by so few.

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