More evidence that deferring treatment can work just fine

Concrete evidence that, for many appropriately selected men, deferred treatment may be a better choice than invasive treatment continues to accumulate. While there is still no category 1 evidence from a large, randomized clinical trial, a newly published article examined data on the management of prostate cancer patients enrolled in the Health Professionals Follow-up Study — a prospective study of 51,529 men.

Shappley et al. calculated the hazard ratios (HRs) for time to eventual treatment among men who deferred treatment for more than 1 year after diagnosis. The HRs for time to metastasis or death as a result of prostate cancer were then compared between patients who deferred treatment and those who underwent immediate treatment within 1 year of diagnosis. The results of their analysis are as follows:

  • 3,331/51,529 cohort participants (6.5 percent) were diagnosed with prostate cancer between 1986 and 2007.
  • 342/3,331 patient (10.3 percent) initially deferred treatment.
  • 174/342 patients who deferred treatment (51 percent) remained untreated throughout follow-up (mean 7.7 years).
  • 168/342 patients who deferred treatment (49 percent) were treated an average of 3.9 years after diagnosis.
  • Factors associated with progression to treatment among DT patients included younger age, higher clinical stage, higher Gleason score, and higher PSA level at diagnosis.
  • The rates for development of metastases were similar between the deferred treatment and the early treatment groups.
    • In the deferred treatment group, 20/342 patients progressed to metastatic disease at a rate of 7.2 per 1,000 person-years.
    • In the early treatment group, 199/2,989 patients progressed to metastatic disease at a rate of 8.1 per 1,000 person-years.
  • The rates for prostate cancer-specific death were also similar between the two groups.
    • In the deferred treatment group, 8/342 patients died of prostate cancer at a rate of 2.4 per 1,000 person-years.
    • In the early treatment group, 80/2,989 patients died of prostate cancer at a rate of 2.6 per 1,000 person-years.

While this study was not conducted as a randomized trial, and while there was no specific protocol being followed by patients who chose to defer treatment, three clear conclusions can be drawn from this community setting-based, national study:

  • > 50 percent of the men who opted for deferred treatment went without treatment for 7.7 years after diagnosis.
  • Older men, and men with lesser cancer severity at diagnosis, were more likely to remain untreated.
  • Prostate cancer mortality did not differ between patients who received deferred as compared to early forms of treatment.

The “New” Prostate Cancer InfoLink is increasingly convinced that we need national guidelines for both the selection of patients who are suitable for deferral of treatment and for the management of such patients based on their type. Active surveillance of some type certainly seems to be wise for those patients in whom curative intervention may still be needed (i.e., patients who have long life expectancies and with a rising PSA) but more conservative forms of management, with deliberate avoidance of excessive biopsying, may be more suitable for men with shorter life expectancies and early stage, low risk disease.

2 Responses

  1. An excellent article. I believe that those men who are over 70 years of age should think long and hard before they pursue any surgical, medicinal or radiographic treatment. The side effects and hence the quality of life is generally very poor. Most doctors are more interested in saving your life and not your quality of life.

  2. I think this statement speaks volumes regarding the PSA test and its sensible use, re “watchful waiting:”

    “If this approach was more broadly accepted as a standard care option for suitable low-risk prostate cancers, it might help us avoid throwing the baby out with the bathwater when it comes to the PSA test,” he adds. “Instead of just abandoning the PSA test because it might be leading to an overdiagnosis of prostate cancer, we could conduct PSA screening in a way that allows more aggressive prostate cancers to be treated, while less aggressive tumors could initially be monitored. This would avoid problems due to treatment of ‘overdiagnosed’ low-risk cancers, while preserving the lifesaving benefits of treating aggressive cancers that have been detected through PSA testing.”

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