So a new paper just published on line in BJU International has (finally) provided some data to support a perspective that The “New” Prostate Cancer InfoLink has believed in for a considerable period of time … that active surveillance is a perfectly reasonable option for a high proportion of patients with low-risk prostate cancer who are ≤ 55 years of age.
In this article by Kim et al., the authors use data from a large Department of Defense tumor registry and related clinical records of the servicemen involved. Their objective was to see if they could identify a population of younger men (aged < 55 years at diagnosis) with very low-risk prostate cancer (clinical stage T1c, with a PSA density of < 0.15 ng/ml/g, a Gleason score ≤ 6, and only one or two positive biopsy cores with < 50 percent tumor involvement) that were potentially good candidates for active surveillance (AS).
They looked specifically at data from patients in two time cohorts:
- Group A: those diagnosed and initially treated between 1987 and 1991
- Group B: those diagnosed and initially treated between 2007 and 2010
Here is what they found:
- Compared to the men ≤ 55 years of age in Group A, men of ≤ 55 years of age in Group B were > 30 times more likely to have been diagnosed with PSA screen-detected tumors.
- Data for a subset (n = 174) of men in Group B with PSA screen-detected cancer were evaluable for disease risk assessment.
- 81/174 men with screen-detected disease (47 percent) had very low-risk disease, as defined above.
- Of that group of 81 men
- 78/81 (96 percent) selected treatment
- 57/81 (70 percent) men elected to be treated by radical prostatectomy.
- 49/57 men who had a radical prostatectomy actually did have tumors with favorable pathology (organ confined, < 10 percent gland involvement, Gleason ≤ 6).
Kim et al. conclude that, “Nearly half of young men with PSA screen-detected prostate cancer are AS candidates but the overwhelming majority seek treatment. Considering that many tumors show favorable pathology [after surgery], there is a possibility that these patients may benefit from AS management.”
Now this study does not provide us with definitive proof what active surveillance is the “correct” management strategy for all men under 55 with low-risk disease. On the other hand, it does provide us with a very real quantification of the size of the problem: some 47 percent of all men ≤ 55 years of age who are diagnosed today with low-risk disease (as defined above) appear to be good candidates for active surveillance.
It should also be noted that (arguably), since the definition actually used by Kim et al. is of men with very low-risk disease, the actual pool of men that requires immediate treatment as opposed to active surveillance at the time of diagnosis is considerably higher.
The point to be borne in mind here is not that early treatment for localized prostate cancer is unnecessary or ineffective in the elimination of their cancer. It is that treatment for low-risk prostate cancer in such men can almost invariably be deferred successfully until it is actually necessary, and then applied with a similar level of success. A key consequence of this decision is that younger men with good continence and good sexual function may be able to retain these for years, as opposed to suffering the potential consequences of early “over”-treatment. Apparently this finding could be reasonably applied to all men in the US who are diagnosed with prostate cancer at ≤ 55 years of age. That is hardly a small number of men on an annual basis. If it can be applied to others outside the US as well, we are starting to talk serious numbers of patients.