Life expectancy, mortality, surgery, risk, and management of localized prostate cancer

A critical factor in understanding why non-treatment (i.e., monitoring with either active surveillance or watchful waiting) may be a better idea than immediate treatment for men with localized prostate cancer has to do with risk of death from causes other than the cancer.

We have previously provided information about the new on-line tool available through the Memorial Sloan-Kettering Cancer Center web site that allows men to assess their life expectancy, based on risk of death from prostate cancer or other causes, if they do not get treatment. A new study by a group of Spanish researchers has now provided similarly suggestive data.

Ruiz-Cerdá et al. set out to use data from their institution to calculate the the risk of prostate cancer-specific mortality (PCSM) and compare in to the competing risk of mortality from other causes (MFOC) in patients with localized prostate cancer who had received surgical treatment for their cancer. For the 900+ patients in their cohort, they carried out a competing risk analysis and calculated the probability of PCSM in the presence of the competing risk of MFOC. Cumulative incidence curves were constructed, and point estimates were performed at 5, 10 and 15 years. The analysis was stratified by age (≤65 vs. >65 years) and risk group: low (Gleason score ≤6 and pT2abc); intermediate (Gleason score of 7 and pT2abc) and high (Gleason score of 8-10 or pT3ab).

Here are their study findings:

  • The study cohort included 982 patients, all treated for localized prostate cancer by radical prostatectomy.
  • The average (median) follow-up was 60 months.
  • The overall probability of PCSM was 3.5 percent.
  • The overall probability of MFOC was 9 percent (about 2.6 times higher than for PCSM).

The authors go on to note that the observed effect remained for all risk groups, although its magnitude did decrease progressively according to the patients’ risk group level:

  • At 10 years of follow-up
    • The probability of PCSM was
      • 0 percent for low-risk patients
      • 1 percent for intermediate-risk patients
      • 2 percent for high-risk patients
    • The probability of MFOC was
      • 4 percent for low-risk patients
      • 4 percent for intermediate-risk patients
      • 10 percent for high-risk patients

The authors point out that, on the basis of these data

The benefit of [radical prostatectomy] might be over-estimated [in men with localized disease], given that the risk of [MFOC] is greater than that of [PCSM], regardless of the age group and risk group [of the patients], especially after 10 years of follow-up.

They also observe that this information could help patients to decide to choose monitoring over surgery — especially in the case of men  localized prostate cancer and short life expectancies.

9 Responses

  1. Radiation proctitis (rectal bleeding) from proton prostate therapy is a undisclosed high risk factor.

  2. So what were the PCSM and MFOC probabilities at 10 years for those at high-risk and > age 65?

  3. Sigh! … Another statistical gyration to “prove” that some meaningful secret is discovered regarding the imminent demise of … not me, not you, and probably nobody we know … because they always gloss over the caveat that statistics apply to preferably large populations, not to particular individuals!

  4. Dear Natron:

    I don’t think anyone is trying to “prove” anything with a paper like this. They are merely offering insight … which you are welcome to ignore.

  5. Dear Bob:

    I have no idea. That information may be in the full text of the paper — if you feel like asking the authors for a copy.

  6. Dear Himalayan:

    Radiation proctitis is a risk factor for any type of radiation of the prostate. And as far as I am aware it is a well understood risk factor. Whether it is a major, “high” risk factor is debatable. Whether it is undisclosed would depend on the center you went to. Most good centers I am aware of would tell patients that there was some degree risk for this.

  7. I have a biopsy question.

    If there are two entry possibilities for a prostate biopsy, namely through the wall of the rectum or through the perineum, and more probability of infection through the rectal wall … why isn’t the perineum the number one entry point instead of being used secondarily?

    D. Duffy

  8. Dear Dick:

    I see that this issue had already come up when you left a question for Ask Arthur.

    I don’t have a good answer to this question either, but I will see if I can get one for you next time I am talking to a really smart urologist.

  9. Dear Dick:

    So I have spoken with a very experienced urologist. His opinion was that: (a) Transrectal biopsies combined with the ultrasound give the surgeon a much better view of where the needles are being placed and a good deal more flexibility when it comes to where the surgeon wants to direct them to in the prostate. (b) Transperineal biopsies, in his experience from when he was asked to do them as part of his training, tend to be much more painful for the patient.

    Obviously, that is just one specialist’s opinion (which he asked me to emphasize).

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