Active surveillance in men with higher-risk forms of localized prostate cancer

The abstract of a paper currently in press in the Journal of Urology has offered us some potentially fascinating insight into the comparative outcomes of patients with low- and higher-risk forms of localized prostate cancer when they are initially managed on active surveillance.

This paper by Nyame et al. comes from the group at The Cleveland Clinic. Since 2002 they have been monitoring 635 men, all diagnosed with localized prostate cancer and all initially managed on active surveillance. What is “different” about this cohort of patients, however, is that 117/635  or 18.4 percent were known at diagnosis to have either intermediate or high-risk forms of prostate cancer.

Unfortunately the full text of this paper is embargoed at the present time, but we have seen the abstract on the PubMed web site. Some of the details in the full text of thsi article may be extremely important, so we need to be cautious about how we interpret the data from the abstract.

Having said that, here is what is reported in the abstract:

  • Among the whole group of 635 men who were initially managed on active surveillance,
    • There were no cases (0 percent) of prostate cancer-specific mortality.
    • Overall, all-cause survival was
      • 98 percent at 5 years
      • 94 percent at 10 years
    • Cumulative, metastasis-free survival was
      • 99 percent at 5 years
      • 98 percent at 10 years
    • Overall freedom from therapeutic intervention (i.e., continued management on active surveillance) was
      • 61 percent at 5 years
      • 49 percent at 10 years
    • Cumulative freedom of failure of active surveillance (i.e., freedom from onset of metastasis or biochemical failure after deferred treatment with curative intent) was
      • 97 percent at 5 years
      • 91 percent at 10 years
    • 21 men (9.9 percent of the roughly 212 men who had deferred therapy with curative intent) had biochemical progression after deferred treatment.
    • The probability of progression-free survival at 5 years among all men who received deferred treatment with curative intent was 92 percent.
  • Compared to the 518 men who were initially diagnosed with low-risk disease, the 117 men who had intermediate- or high-risk disease showed
    • No increase in occurrences of metastasis
    • No increase in occurrences of failure of active surveillance
    • No increase in occurrences of intervention with curative treatment

Now it does have to be noted, however, that the higher-risk patients did experience significantly higher risk for all-cause mortality, but the authors state that this effect is likely to be a reflection of patient selection factors.

As indicated above, we have to be very cautious about treading too much into these data, but they are somewhat unexpected, and the authors do conclude that

Patients with localized prostate cancer on [active surveillance] demonstrated a low rate of [active surveillance]  failure, prostate cancer specific mortality, metastases, regardless of baseline risk.

What this paper appears to be showing us is that there may be a significant number of men with higher-risk forms of localized prostate cancer who can defer treatment for significant period of time without increasing their risk for either failure of treatment with curative intent or onset of metastasis. However, whether we can identify these patients with accuracy up front is a whole other question. The other thing we need to appreciate is that these outcomes may look very different at 15 or 20 years of follow-up.

4 Responses

  1. Still, it’s good news for many patients.

  2. …us 3 + 4 (no-cribriform) dice-rollers…

  3. Some men like to wear belts and suspenders too. Others are more willing to take risk. This is an individual decision. There are no “rights” and “wrongs” … only differing levels of potential risk and potential reward.

  4. Yes. I would never suggest it’s for everyone, or “right” (maybe even for me, in time). Having an appalling memory helps.

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