The downsides of conservative management

There is increasing evidence in support of conservative methods (active surveillance or watchful waiting) for management of early stage, low risk prostate cancer in men with a life expectancy of ≤ 10 (or perhaps even ≤ 15) years. However, it should never be forgotten that prostate cancer progression can cause a whole range of problems in and of itself, potentially including:

  • Fear and anxiety
  • Impotence
  • Incontinence
  • Urinary blockage
  • Kidney failure
  • Bone metastasis
  • Compression fractures
  • Major organ metastases leading to major symptoms and death

To date we appear to have only one study that has compiled a thorough analysis of the frequency of adverse events associated with conservative management in a large, well-defined patient population over time.

In February 2008, Lu-Yao et al. presented data based on the progression of prostate cancer among men who received initial conservative management for early-stage disease in the PSA era. All patients were diagnosed between 1992 and 2002 and received no initial local therapy or androgen deprivation therapy within 6 months of their diagnosis.

The study included 9,018 men, more than 5,000 of whom were > 75 years of age: 64 percent had T1 disease and 36 percent had T2 disease. Study data were obtained from Medicare claims data linked with the Surveillance, Epidemiology, and End Results (SEER) database.

The results of this study showed that, at 5 years post-diagnosis:

  • 2,391/9,018 men (26.5 percent) received some form of therapy
  • 259/7,224 men (3.6 percent) received a TURP as a consequence of their cancer*
  • 29/9,018 men (0.3 percent) required treatment for spinal cord compression
  • 344/9,018 men (3.8%) had died of prostate cancer

Similarly, at 10 years post-diagnosis:

  • 2,675/9,018 men (29.7 percent) received some form of therapy
  • 324/7,224 men (4.5 percent) received a TURP as a consequence of their cancer*
  • 44/9,018 men (0.5 percent) required treatment for spinal cord compression
  • 482/9,018 men (4.2 percent) had died of prostate cancer, including 11/187 (5.9 percent) with low grade disease, 256/7,544 (3.4 percent) with moderate grade disease, and 215/1,287 (16.7 percent) with high grade disease

Additional data from this study showed that:

  • Median age at diagnosis was 77 years (range: 66 to 104 years)
  • Median follow-up was 94 months
  • Median time to any cancer therapy (surgery, radiation, chemotherapy or androgen deprivation) was 127 months
  • During the study period, 6,523/9,018 of the study cohort (72 percent) died of competing causes of death or had no documented cancer complications that required surgery or radiation
  • The corresponding statistics for low, moderate, and high grade cancers were 162/187 (86.6 percent), 5,521/7,544 (73.2 percent), and 840/1,287 (65.3 percent), respectively

These data are in fact striking because they demonstrate that 6,343/9,018 or 70.3 percent of the patients in this study never required or received treatment for their prostate cancer in a relatively modern cohort of patients diagnosed during the PSA era. It is perhaps regrettable that we don’t have more information about the precise reasons why the patients who did have therapy needed it.

By contrast, the survival of conservatively managed patients with poorly differentiated prostate cancer is dismal, and the quality of life of patients initially diagnosed with localized but high risk prostate cancer is significantly affected by the occurrence of distant metastasis. As long ago as 1994, Chodak et al. clearly demonstrated that, among patients initially diagnosed with T1 and T2 forms of prostate cancer, the risk of metastatic disease at 10 years of follow up was:

  • 19 percent for well-differentiated cancers
  • 42 percent for moderately differentiated cancers
  • 74 percent for poorly differentiated cancers

In the same publication, Chodak et al. reported that prostate cancer-specific mortality in the same patient group was:

  • 13 percent for well- and moderately differentiated cancers
  • 66 percent for poorly differentiated cancers

The seminal study of data from the Connecticut Tumor Registry by Albertsen et al. clearly demonstrated that men whose biopsy specimens show Gleason scores between 7 and 10 have a high risk of death from prostate cancer when treated conservatively, even when cancer is diagnosed as late as age 74 years. Specifically, their data indicated that, at 15 years of follow-up, when managed conservatively:

  • Men with Gleason 7 disease at diagnosis had a 42 to 70 percent probability of cancer-specific death
  • Men with Gleason scores of 8 to 10 at diagnosis had a 60 to 87 percent probability of cancer-specific death

It should also be pointed out that, when such patients do receive treatment it will almost inevitably require hormonal therapy, and so they will almost inevitably suffer from some or all of the adverse effects of androgen ablation, potentially including impotence, hot flashes, memory loss, weight gain, gynecomastia, osteopenia, osteoporesis, etc., etc.

The “New” Prostate Cancer InfoLink wishes to emphasize that, while conservative management is most certainly a highly appropriate management strategy for many men (and particularly older men) with low and moderate risk forms of prostate cancer, it is rarely appropriate for men (and particularly younger men) diagnosed with higher risk disease, because of the well-defined risks for cancer-specific death and cancer-associated complications.

*Excludes  men who had a transurethral resection of the prostate or TURP prior to diagnosis of prostate cancer.

Content on this page last reviewed and updated February 21, 2009.
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