How young men have thought about treatment options for Gleason 6 prostate cancer


A new study based on data from nearly 500 patients gives us some insight into how a selected group of men less than 50 years of age were thinking about treatment for prostate cancer between 2001 and 2005. Whether one would get the same results for a similar group of patient diagnosed today is a good question.

The paper by Sidana et al. is based on a cohort of 986 men — all under 50 years of age and all confirmed to have Gleason 3 + 3 = 6 prostate cancer after they had sought a pathologic opinion on their biopsy specimens from Dr. Epstein and colleagues at Johns Hopkins Medical Center between 2001 and 2005.

We need to recognize immediately that these were hardly “average” patients. They were clearly motivated in some way to get a specialist opinion on their biopsy cores (although it is not clear whether this was always at the patient’s request or might have been at the suggestion of their own doctor).

Sidana et al. mailed a detailed questionnaire to all 986 patents, with the following results:

  • 493/986 men (exactly 50 percent) responded.
  • The men with some degree of college education or with an annual income >$100,000 were significantly more likely to have
    • Consulted three or more doctors before making a treatment decision
    • Considered sexual function to be important in making a treatment choice
  • Men reported that “doctor’s recommendation” was the most influential information source in making their treatment decision.
  • The Internet was reported to be the second most frequent source of information.
  • The vast majority of these patients had selected one of three common forms of first-line management:
    • Radical prostatectomy (n = 393, 81.4 percent)
    • Radiation therapy (n = 52, 10.7 percent)
    • Active surveillance (n = 26, 5.3 percent).
  • With respect to the actual decision-making process
    • 2 percent of patients preferred a passive role.
    • Patients who chose radiation and active surveillance preferred “informed decision-making.”
    • Patients who chose surgery preferred “shared decision-making.”
    • The “doctor’s recommendation” was of less importance to men electing active surveillance as a first-line management option.
  • Most patients (89 percent) stated that they did not regret their decision.
  • There was no significant difference in satisfaction levels between patients who had selected different types of therapy.

It is hard to know exactly what to make of these data since it is divorced from any data about the patients’ immediate and long-term outcomes.

The fact that patients report that “doctor’s recommendation” and the Internet were their two primary influential information sources is hardly a revelation. Nor is the fact that there was a high level of satisfaction regardless of the type of treatment selected.

In the period from 2001 to 2005 it is probably fair to say that the application of radical surgery as a first-line treatment for low-risk prostate cancer was at a very high level of acceptance, and that many men were not fully aware of the potential risks to sexual function associated with radical surgery. We also assume that the 52 men in this sample who elected radiation therapy included men who had proton beam radiation therapy or brachytherapy, and not just standard forms of external beam radiation therapy.

What can not be told from this study is whether these young men made “good” decisions. All we can tell is what their decision was and what influences may have played a factor in reaching that decision.

2 Responses

  1. Mike: This was an interesting article. What made it even more interesting was the group of articles recently reviewed here. What caught my attention was the group of articles that focused on various strata of the men who are tested and treated for prostate cancer. So many of the general interest articles seen on prostate cancer lump all men regardless of age together to comment on what should or should not be done as effective treatments. Without any careful reading or differentiation, the average reader might be fooled into thinking that all prostate cancer is over-treated and that everyone should hold back on aggressive treatment because the disease can be so slow in progressing. I find that lots of comments tend to be so broad based that they can really be harmful to some who think at age 50 that they should not be so concerned with getting treatment. Flooded with over-diagnosed disease, Gleason 6 is barely cancer at all, side effects are worse than the disease all point to amassing confusion to the issue for many men. Then you have doctors who downplay the PSA and subsequent treatment and it all seems to conspire to make an individual believe that doing less is the better alternative. Thanks again for showing various age stratified segments in the selection of articles to review. What a > 65-year-old should do with Gleason 6, small focus biopsy results is different than what a 50 year old who get the same diagnosis, especially if the younger patient is in good health.

  2. Mike:

    Don’t think only about the Gleason score. It is the combination of Gleason score, PSA, clinical stage, and amount of cancer on biopsy that is important. Two men of 60 could both have clinical stage T1c, a PSA of 4.2 ng/ml, and a Gleason score of 3 + 3 = 6. However, one might have 4/12 positive biopsy cores, each positive core with > 50% positive for cancer; the other might have only 1/12 positive core with < 5% of that core positive for cancer. It seems likely that the former may need treatment whereas the latter may not.

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