What is the risk of NOT treating PSA-detected prostate cancer?


A new article in the May issue of Cancer Epidemiology, Biomarkers and Prevention appears to be a first attempt to project population-based probabilities of the occurrence of clinically significant prostate cancer among men who are diagnosed with prostate cancer but who receive no treatment.

For the purposes of this study, Gulati et al. define clinically significant prostate cancer as prostate cancer that “would have been clinically diagnosed in the absence of [PSA testing] and that … [might] metastasize or lead to death in the absence of treatment.”

Gulati and his colleagues have used a range of historic data and three independently developed models of the natural history of prostate cancer to project the risks of specific events associated with clinical progression of prostate cancer — including prostate cancer-specific mortality — in men who never received PSA tests or early treatment for their prostate cancer. They were then able to further project the same risks in men who did have PSA tests, got diagnosed earlier, and therefore could receive earlier treatment (but didn’t).

The results projected by their three different models show the following:

  • Between 20 and 33 percent of all men in the USA aged between 50 and 85 years of age have “preclinical” onset of prostate cancer (i.e., prostate cancer would be found in an autopsy specimen but there is no clinical evidence of the disease at its onset).
  • Of these men with “preclinical” prostate cancer, in the absence of PSA testing,
    •  38 to 50 percent would be clinically diagnosed at some time after the “preclinical” onset.
    • 5 to 9 percent would have evident metastatic disease at the time of clinical diagnosis.
    • 12 to 25 percent would die from their prostate cancer.
  • The preclinical period averages between 7 and 14 years.
  • PSA testing can identify risk for prostate cancer (and therefore the potential need for a biopsy), on average, between 4 and 9 years prior to clinical evidence of risk.
  • For men of 50 to 59 years of age whose cancer risk is identified by PSA testing and who are diagnosed with a Gleason score of between 2 and 7
    • The probability that they would be clinically diagnosed in the absence of PSA testing is 67 to 93 percent.
    • The probability that they would die of prostate cancer in the absence of primary treatment is 23 to 34 percent.
    • 4 to 9 percent would die of prostate cancer within 10 years of diagnosis.
    • 15 to 26 percent would die of prostate cancer within 20 years of diagnosis.
  • For men of 50 to 59 years of age whose cancer risk is identified by PSA testing and who are diagnosed with a Gleason score of between 8 and 10
    • The probability that they would be clinically diagnosed in the absence of PSA testing is 90 to 96 percent.
    • The probability that they would die of prostate cancer in the absence of primary treatment is 63 to 83 percent.
    • 29 to 43 percent would die of prostate cancer within 10 years of diagnosis.
    • 56 to 68 percent would die of prostate cancer within 20 years of diagnosis.

The key point to be understood from this study is that “Risks of disease progression among untreated PSA-detected cases can be nontrivial, particularly for younger men and men with high Gleason scores.”

While this is not new knowledge, models like this may be helpful as we build better prognostic tools based on the growing quantity of data from studies of men on active surveillance protocols and the long-term follow-up of men who receive differing types of first-line therapy. Making well-informed decisions about the need for treatments of prostate cancers detected after a routine PSA test requires this type of detailed knowledge about the natural history of prostate cancer.

It is worth noting that, on the basis of these three models, between 50 and 62 percent of all preclinical and potentially detectable prostate cancers in men aged between 50 and 85 years of age would never, in fact, become clinically significant.

5 Responses

  1. Perhaps the UK’s NHS should read this page. They have taken 5 months to give me a biopsy, and 4 weeks on from the biopsy I do not know the results. “Glad it is not urgent.” PSA 7; age 66: what are the odds?

  2. The UK NHS regularly treats prostate cancer as a trivial disease of “old men.” Patients here regularly wait months for biopsies and then 6 months for treatment. Truly appalling compared to the USA and other countries.

  3. Perhaps the NHS should wear the pants, and try living without knowing the results for months. I just want to know if I have it or not, “amen”.

  4. In Finland it worked like this:

    — First blood test result in 3 days; PSA 43
    — Second blood test 6 weeks later; result following week, PSA 46
    — 7th week from first blood test, biopsy, ultrascan, full body scan
    — 8th week metastic prostate cancer diagnosed; 2- to 3-year average life expectancy with treatment, months without; orchiectomy recommended
    — 8th week + 4 days; operation complete.

    So just under 9 weeks from first blood test to orchiectomy.

    Finland is fast and my family wants me to return to the UK! I am still studying , working, and walking.

  5. Dear Zearro:

    The original article above was not actually about the diagnosis and treatment of metastatic prostate cancer but of much earlier stage disease.

    You might also want to be aware that men who respond well to hormonal therapy for metastatic prostate cancer can live a very great deal longer than 2 to 3 years. There are a significant number of men of my acquaintance who have been living with metastatic disease for over 10 years!

    You would be wise to get an opinion on your case from a medical oncologist who specializes in the management of prostate cancer. If you do return to the UK, a good place to get that second opinion would be somewhere like the Royal Marsden Hospital in Surrey.

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