Improving prognostic guidance for men with advanced and progressive forms of prostate cancer

A recent report on Renal & Urology News discusses long-term follow-up data from a cohort of > 2,600 prostate cancer patients who were followed from diagnosis for up to 10 years until their deaths.

Unfortunately, the report in R&UN starts as follows:

Men with advanced prostate cancer (PCa), especially those with castration-resistant prostate cancer (CRPC), have an elevated risk of disease-related complications near the end of life, including spinal cord compression and renal failure, according to study findings presented at the American Society of Clinical Oncology’s 2018 Annual Meeting in Chicago.

The implication that men with advanced prostate cancer “have an elevated risk of disease-related complications near the end of life” is certainly factually accurate, but it was hardly the primary finding of this piece of research reported at ASCO in the poster presented by Yerramilli et al. An elevated risk for complications among men with advanced forms of prostate cancer has been well appreciated for about 100 years or more.

Your sitemaster actually spent quite some time at the ASCO meeting speaking with Dr. Yerramilli in respect to her poster.

What the poster actually addressed was the level of risk for certain very specific and serious complications as a consequence of progressive prostate cancer by the time of patient death, based on information about the patients’ status at the time of initial diagnosis and their subsequent progression over time — and it is highly relevant to this that:

  • The average (mean) age of these patients at time of diagnosis was 67.6 years at diagnosis.
  • Their mean age at death was 70.1 years.
  • The full cohort of 2,603 patients included
    • 490 men (18.8 percent) with low- or intermediate-risk prostate cancer at time of diagnosis
    • 617 men (23.4 percent) with high-risk prostate cancer at time of diagnosis
    • 1,005 men (38.6 percent) with metastatic disease at diagnosis
  • Among the patients with metastatic disease at time of death
    • 519 men had castration-resistant prostate cancer
    • 481 men had hormone-sensitive prostate cancer

To quote Dr. Yerramilli, what she and and her colleagues had been trying to do was to develop data that could be used to assist clinicians

to explain the natural history of this disease to their patients, and discuss upfront management strategies in the context of the development of these major disease-related events.

This is actually, often, a difficult challenge. Only this morning your sitemaster heard from a patient who has now become castration-resistant and who noted that his doctors seemed to be unable (or perhaps unwilling) to talk to him about his long-term prognosis — in his case, in particular, because he has cardiovascular issues that make him a poor candidate for treatment with chemotherapy or with a second-generation form of ADT like abiraterone acetate (Zytiga) + prednisone.

A table shown in the abstract of the poster presentation gives the specific levels of risk and the times to any first event for five common complications of late stage prostate cancer:

  • Any level of bone metastasis
  • Any clear sign of a pathological fracture
  • Any clear indication of spinal cord compression
  • Obstruction of the ureter
  • Renal failure as a consequence of ureteric obstruction

The table also correlates this information to the patients’ status at time of diagnosis (as listed above), and the same information is also reported lower down in the commentary in R&UN.

This information is — potentially — of considerable value in  helping clinicians to provide patients with individualizable information about their risk for these specific complications over time as their disease progresses.

3 Responses

  1. That is useful. Patients should be aware that there is a mistake in the results section: “High risk men had bone metastases (BM) 2.9 months from diagnosis (IQR 1.7-4.9) versus men with low/int. risk disease (4.2 mos, 2.8-6.3), p < 0.001. "Months" should be "years," according to the table below. "Months" would have been scary.

  2. Thanks for noting this Allen.

  3. For men with low- to intermediate-risk disease at diagnosis to potentially have bone metastasis in just 4.2 years seems unlikely unless there was BCF or it had been shown that prostate cancer cells had already left the prostate, which would have been metastatic. The report lead in almost sounds like all men had advanced prostate cancer at diagnosis which I think was not the intent considering the risk level chart breakdown.

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