Two recent publications have offered evidence that, at 10 and 12 years of follow-up, the potential benefits of surgical treatment for low- and intermediate-risk prostate cancer did not include any impact on overall survival for men of 65 years of age or more at the time of surgery.
Shao et al. have now carried out a careful analysis of data from patients aged 70 years and older, diagnosed with prostate cancer between 2004 and 2005 and identifiable in the Surveillance, Epidemiology and End Results (SEER)-Medicare database, and of their Medicare claims before their cancer diagnosis (during the years 2000 to 2005). The researchers’ objective was to explore whether a history of earlier and frequent PSA testing had a subsequent impact on the likelihood of immediate active intervention (as opposed to active surveillance or watchful waiting) at the time of diagnosis.
Here are the key findings of the study:
- Of the men diagnosed with prostate cancer in the period 2004 to 2005 and aged 70 years or older, > 45 percent had had four to six prior PSA tests between 2000 and 2005 and comprised a “highest testing” group.
- Among the men in this “highest testing” group
- 75 percent were diagnosed with low- or intermediate-risk, localized disease.
- 77 percent received active treatments within 180 days of cancer diagnosis.
- Men in this “highest testing” group were 3.57 times more likely to receive treatments (including surgery, radiation, or hormonal therapy) when compared with men who had had no prior PSA tests between 2000 and 2005.
- Among men aged 75 years and older diagnosed with low-risk cancer, those in the “highest testing” group were 78 percent more likely to receive treatment than those who had no prior PSA tests between 2000 and 2005.
The authors conclude that, given the lack of evidence of the clinical value of early treatment for elderly men with low- and intermediate-risk, localized prostate cancer and our inability to differentiate accurately between indolent and aggressive disease at the time of diagnosis, frequent PSA testing may be increasing the risk of over-treatment of elderly men with relatively low-risk forms of prostate cancer who are at very limited risk for clinically significant disease.
The diagnosis and management of localized prostate cancer among men of 70+ years of age is becoming an increasingly controversial issue as it becomes clearer that a significant proportion of men of this age actually receive little to no clinical benefit from immediate intervention. On the other hand, those men who have potentially aggressive or high-risk disease clearly do still need early intervention in order to limit their risk for subsequent metastatic disease or prostate cancer-specific mortality.
It also makes perfect sense that those men who are (rightly or wrongly) most concerned about their risk from prostate cancer, and who have been getting regular PSA tests over a 5-year (or longer) period, are also the ones most likely to seek immediate intervention if prostate cancer is diagnosed — even in their mid to late 70s, with a probable life expectancy of < 15 years.
What we are facing here is a socio-cultural problem, in which immediate treatment for early stage cancer has become (for several reasons) “the norm” despite good evidence that, in the case of many (but not all) elderly men with localized prostate cancer, the potential benefits of treatment may be substantially lower than the potential risks. Without better tests to clearly be able to differentiate the truly aggressive forms of cancer from the indolent and non-aggressive forms at diagnosis, and without 20-year follow-up data (as yet) from trials like the Scandinavian study and the PIVOT trial, it is very difficult to look any individual patient straight in the eye and tell him that immediate treatment is a really bad idea. The cultural prejudice to just “get that cancer outta there” is strong, and many men will express high satisfaction with the results of their treatment despite a significant (even if mild) set of side effects and no evidence of actual therapeutic benefit.
Filed under: Living with Prostate Cancer, Management, Treatment | Tagged: benefit, complication, elderly, localized, outcome, over-treatment, risk, side effect |
THE "NEW" PROSTATE CANCER INFOLINK 
In a perfect world, every conversation about PSA testing and/or prostate cancer treatment would start with the physician and patient reading and discussing the article by Ransohoff et al. (published in 2002) on the lack of a negative feedback loop associated with the putative benefits of screening and treatment.
STUDY PREDATES MOST ACTIVE SURVEILLANCE PAPERS
I found this study interesting. I believe it has long-term value, but what we can tell low-risk patients now is much different from what we could tell them when this group was diagnosed, back in 2004 through 2005.
The first substantial paper I know of on results from an active surveillance (AS) series was the Klotz paper from the Toronto group published in 2003. Even then the results were tentative, and the term “active surveillance” was just emerging. Johns Hopkins also published a tentative paper that year on their “expectant management” program. Memorial Sloan-Kettering published its initial results in 2004, the first year in which men in the subject study were diagnosed. The Erasmus Medical Center produced a very tentative paper in 2004, but solid results from its series did not appear until 2007. Dr. Babaian’s group at M. D. Anderson also began publishing papers on AS about that time, with Dr. Carroll’s group at UCSF also becoming increasingly prolific during the latter half of the decade.
These are among the leading AS programs, and it is clear that it required an act of faith back in 2004 and 2005 for a patient to commit to AS. There just was not enough solid data published back then, and it is doubtful that many urologists were up to speed on the approach. “Heal with steel” was the urologist’s motto in the first half of the decade.
In sharp contrast, we now have a number of leading programs publishing highly encouraging results from rather long running AS programs. We also have firm endorsement of AS from leading guideline organizations like the NCCN and AUA. Hopefully those results and endorsements will go a long way toward reassuring today’s newly diagnosed low-risk patients that AS is a sound approach. I’m thinking that a study taking the approach of the Shao study for men diagnosed in the past couple of years would show substantially greater and increasing acceptance of AS by low-risk patients.