Long-term survival in a Swedish population-based cohort of men with prostate cancer

The Clinical Utility of Systemic Immune-Inflammation Index Supporting Charlson Comorbidity Index and CAPRA-S Score in Determining Survival after Radical Prostatectomy-A Single Centre Study

The selection of candidates for the curative treatment of PCa requires a careful assessment of life expectancy. Recently, blood-count inflammatory markers have been introduced as prognosticators of oncological and non-oncological outcomes in different settings. This retrospective, monocentric study included 421 patients treated with radical prostatectomy (RP) for nonmetastatic PCa and aimed at determining the utility of a preoperative SII (neutrophil count × platelet count/lymphocyte count) in predicting survival after RP. Patients with high SIIs (≥900) presented significantly shorter survival (p = 0.02) and high SIIs constituted an independent predictor of overall survival [HR 2.54 (95%CI 1.24−5.21); p = 0.01] when adjusted for high (≥6) age-adjusted CCI (ACCI) [HR 2.75 (95%CI 1.27−5.95); p = 0.01] and high (≥6) CAPRA-S [HR 2.65 (95%CI 1.32−5.31); p = 0.006]. Patients with high scores (ACCI and/or CAPRA-S) and high SIIs were at the highest risk of death (p < 0.0001) with approximately a one-year survival loss during the first seven years after surgery. In subgroup of high CAPRA-S (≥6), patients with high ACCIs and high SIIs were at the highest risk of death (p <0.0001). Our study introduces the SII as a straightforward marker of mortality after RP that can be helpful in pre- and postoperative decision-making.

OUP accepted manuscript

Background

Methods

Results

Conclusions

What is the best approach for screen-detected low volume cancers?--The case for observation

The case for active surveillance as the optimal therapy for screen detected, low volume, low grade prostate cancer is presented. This is based on data from recent long term studies of conservative management, the prostate cancer prevention trial (PCPT), the Swedish trial of radical prostatectomy vs. observation, and several large Phase 2 trials of active surveillance. These studies indicate convincingly that (1) widespread screening results in a diagnosis of prostate cancer in many patients with clinical insignificant disease, (2) that these patients can be identified with reasonable accuracy, (3) that delayed intervention does not appear to put those patients who reclassify as higher risk over time at significant risk, and (4) that the psychological burden of surveillance is acceptable.

Active surveillance for prostate cancer: trials and tribulations

INTRODUCTION

Prostate specific antigen (PSA) screening results in the detection of prostate cancer in many men who are not destined to die from the disease. This often results in overtreatment. One approach to reducing the overtreatment effect is to treat selectively by observing patients with favorable risk disease, and treating only the subsets who are reclassified as higher risk over time, based on biochemical or pathologic progression of disease.

METHODS

The data supporting the active surveillance concept is reviewed, including the results of several large-scale Phase 2 studies. A number needed to treat analysis was performed based on these studies and a large randomized trial of radical prostatectomy versus watchful waiting. The arguments in favor of, and opposed to, active surveillance are presented.

RESULTS

The largest, most mature Phase 2 study of active surveillance has reported an 85% overall survival and 99% disease-specific survival with a median follow-up of 8 years (range 2-11 years). The number needed to treat analysis suggests that between 80 and 100 radical prostatectomies would be required for each prostate cancer death avoided in a favorable risk, screen detected population.

CONCLUSION

Active surveillance appears to be safe for favorable risk prostate cancer and represents an appealing alternative to radical treatment for all newly diagnosed men. Further follow-up and a randomized study design are required to conclusively demonstrate the safety of this approach over the 15- to 20-year time frame. A large-scale randomized trial has recently been initiated internationally to address this question.

The 20-Yr Outcome in Patients with Well- or Moderately Differentiated Clinically Localized Prostate Cancer Diagnosed in the Pre-PSA Era: The Prognostic Value of Tumour Ploidy and Comorbidity

OBJECTIVE

This observational cohort study describes the long-term outcome of patients with clinically localized prostate cancer managed with watchful waiting, the prognostic value of tumour ploidy, and the impact of comorbidity.

METHODS

A total of 119 patients with clinically localized (T1-2) prostate cancer consecutively diagnosed from 1978 to 1982 were prospectively managed by watchful waiting, with treatment given if progression occurred.

RESULTS

Median age was 68 yr. Median observation time was 24 yr+/-6.25 (SD). Of the 112 patients who died, 42 died of prostate cancer. Disease-specific survival rates were 85% (95% CI: 77-93%), 58% (46-70%), and 32% (19-46%) at 10, 15, and 20 yr, respectively. Treatment-free survival rate was 43% (95% CI: 33-54%) at 10 yr. Patients aged 70 yr and over had a statistically significant increased risk of dying from any cause. There was a statistically significant increased risk of dying from prostate cancer for patients with nondiploid tumours.

CONCLUSION

In the present series from the pre-PSA era, watchful waiting yielded a relatively high long-term disease-specific survival rate in patients with well- or moderately differentiated clinically localized prostate cancer, and almost half were not treated 10 yr after diagnosis. Watchful waiting may be an option at least for such patients with a 10- to 15-yr life expectancy. Age of 70 yr or more predicted an increased overall mortality. High comorbidity increased the risk (although not statistically significant) for death from any cause and for death from prostate cancer. Patients with nondiploid tumours were at an increased risk to die from prostate cancer.

Adenocarcinoma of the prostate in Iceland: a population-based study of stage, Gleason grade, treatment and long-term survival in males diagnosed between 1983 and 1987

OBJECTIVE

To investigate adenocarcinoma of the prostate in a single population with an extended follow-up period.

MATERIAL AND METHODS

Using the Icelandic Cancer Registry, we identified all Icelandic men diagnosed with prostate cancer between 1983 and 1987. Disease stage, initial treatment and follow-up information were obtained from hospital records and death certificates. A critical evaluation was made of the accuracy of the death certificates regarding prostate cancer. All available histology information was reviewed and graded according to the Gleason grading system.

RESULTS

A total of 414 men were diagnosed with adenocarcinoma of the prostate. Of these, 370 were alive at the time of diagnosis and stage could be determined. Four stage groups were defined: focal incidental (n=50); localized (n=164); local advanced (n=32); and metastatic disease (n=124). The mean age at diagnosis was 74.4 years (range 53-94 years). The combined Gleason score was 2-5 in 89, 6-7 in 117, 8-10 in 117 and unknown in 47 cases. The median follow-up period for the group was 6.15 years (range 0.3-19.8 years). Thirty men received treatment with curative intent: radiation therapy, n=20; and radical prostatectomy, n=10. A total of 334 patients died during the follow-up period, of whom 168 (50%) died of prostate cancer. Prostate cancer-specific survival at 10 and 15 years was 100% and 90.6%, respectively for focal incidental cancer; 73.1% and 60.8% for men with localized disease; 23.4% and 11.7% for local advanced disease; and 6.81% and 5.45% for metastatic disease. A Cox multivariate analysis showed age, stage and Gleason score to be independent predictors of prostate cancer death. A total of 104 patients with localized disease and a Gleason score of <or=7 received deferred treatment. The cause-specific survival for this group was 95.6%, 86.5% and 79.2% at 5, 10 and 15 years, respectively. Death certificates were judged to be accurate with regard to prostate cancer in nearly all instances (96%).

CONCLUSIONS

During an extended follow-up period, half of all patients with prostate cancer died from the disease. Males with localized disease and a favorable tumor grade fared well with deferred treatment. However, a higher stage and grade were associated with substantial prostate cancer mortality. Death certificates were accurate as far as prostate cancer was concerned.

Modeling Prostate Specific Antigen Kinetics in Patients on Active Surveillance

PURPOSE

Prostate specific antigen doubling time was used to stratify patients into groups at low and high risk for progression. The prostate specific antigen kinetics in these 2 groups were modeled.

MATERIALS AND METHODS

In this prospective, single-arm cohort study patients with favorable clinical parameters (stage T1b-T2b N0M0, Gleason score 7 or less, prostate specific antigen 15 ng/ml or less) were conservatively treated with watchful waiting. Evolution of serial prostate specific antigen measurements over time was estimated from a general linear mixed model of the natural log of prostate specific antigen. The corresponding average and individual prostate specific antigen doubling times were also calculated.

RESULTS

Since November 1995 a total of 231 patients had at least 6 months of followup and at least 3 prostate specific antigen measurements. Based on prostate specific antigen doubling time and repeat biopsy, 93 patients fulfilled the criteria for high risk of disease progression and 138 were defined as low risk. Given the baseline status of these individuals, 2 reference average lines (high risk and low risk) were derived to model the evolution of prostate specific antigen levels and permit more rational decision making regarding the need for definitive intervention. The average prostate specific antigen doubling time was 2.97 years (95% CI 2.2-4.4) in patients allocated to the high risk group and 6.54 years (95% CI 4.8-12.3) in those at low risk.

CONCLUSIONS

By applying the dynamic prognostic rule in combination with serial biopsy, a rational decision for definitive intervention based on the risk of disease progression could be optimally recommended about 2.3 years after initiated surveillance.

Active surveillance with selective delayed intervention for favorable risk prostate cancer

Good risk prostate cancer, defined as a Gleason score of < or = 6, prostate-specific antigen (PSA) <10, and T1c-T2a, now constitutes 50% of newly diagnosed prostate cancer. Recent data from the Prostate Cancer Prevention Trial, Stamey data set on PSA-prostate cancer correlations, and the Surveillance, Epidemiology, and End Results database make it very clear that a policy of PSA screening with biopsy for those patients in whom PSA is increased results in the diagnosis, and radical treatment, of a very large proportion of men who do not have life-threatening prostate cancer. Most men with good risk prostate cancer have indolent and slow growing disease. The challenge is to identify those patients who are unlikely to have significant progression, while offering radical therapy to those who are at risk. The approach to favorable risk prostate cancer described in this article uses estimation of PSA doubling time (DT) and repeat biopsy to stratify patients according to the risk of progression. Patients who select this approach are treated initially with active surveillance. Those patients who have a PSA DT of < or = 3 years (based on a minimum of 3 determinations over 6 months) are offered radical intervention. The remaining patients are closely monitored with serial PSA and periodic prostate repeat biopsy at 1, 4, 7, and 10 years. In one series of 299 patients treated in this way, 65% remained free of treatment at 8 years. The prostate cancer specific survival using this approach was 99.3% at 8 years. The majority of patients in this study remain on surveillance. Active surveillance with selective delayed intervention based on PSA DT is a practical middle ground between radical therapy for all, which results in over-treatment of patients with indolent disease, and watchful waiting with palliative therapy only, which results in under-treatment of those with aggressive disease.

Proton therapy of cancer: potential clinical advantages and cost-effectiveness

Proton therapy may offer potential clinical advantages compared with conventional radiation therapy for many cancer patients. Due to the large investment costs for building a proton therapy facility, however, the treatment cost with proton radiation is higher than with conventional radiation. It is therefore important to evaluate whether the medical benefits of proton therapy are large enough to motivate the higher costs. We assessed the cost-effectiveness of proton therapy in the treatment of four different cancers: left-sided breast cancer, prostate cancer, head and neck cancer, and childhood medulloblastoma. A Markov cohort simulation model was created for each cancer type and used to simulate the life of patients treated with radiation. Cost and quality adjusted life years (QALYs) were used as primary outcome measures. The results indicated that proton therapy was cost-effective if appropriate risk groups were chosen. The average cost per QALY gained for the four types of cancer assessed was about pounds 10,130. If the value of a QALY was set to pounds 55,000, the total yearly net benefit of treating 925 cancer patients with the four types of cancer was about pounds 20.8 million. Investment in a proton facility may thus be cost-effective. The results must be interpreted with caution, since there is a lack of data, and consequently large uncertainties in the assumptions used.

Active surveillance with selective delayed intervention: using natural history to guide treatment in good risk prostate cancer

PURPOSE

This article reviews the data supporting an approach of active surveillance with selective delayed intervention for good risk localized prostate cancer. The challenge is to identify those patients who are not likely to experience significant progression, while offering radical therapy to those who are at risk.

MATERIALS AND METHODS

A prospective phase 2 study of active surveillance with selective delayed intervention was initiated in 1995. Patients were treated initially with surveillance, while those who had a prostate specific antigen (PSA) doubling time (DT) of 2 years or less, or grade progression on re-biopsy were offered radical intervention. The remainder were closely monitored.

RESULTS

The cohort consisted of 299 patients with good risk prostate cancer or intermediate risk prostate cancer in men older than 70 years. Median PSA DT was 7.0 years and 35% of the men had a PSA DT of greater than 10 years. The majority of patients remain on surveillance. At 8 years overall actuarial survival was 85% and disease specific survival was 99%.

CONCLUSIONS

Most men with favorable risk prostate cancer will die of unrelated causes. The approach of active surveillance with selective delayed intervention based on PSA DT represents a practical compromise between radical therapy in all, which results in overtreatment in patients with indolent disease, and watchful waiting with palliative therapy only, which results in under treatment in those with aggressive disease. Results at 8 years are favorable. Longer followup will be required to confirm the safety of this approach in men with long (greater than 15-year) life expectancy.

Alternativas terapéuticas en el cáncer de próstata localizado. Experiencia sobre 454 pacientes

OBJECTIVES

To evaluate the influence of different therapeutic options on progression-free survival (PFS), overall survival (OS) and specific survival (SS) in a cohort of 454 patients with localized prostatic carcinoma, taking into account different prognostic factors, and to compare our results to those reported in the world literature.

MATERIAL AND METHODS

Between 1983 and 2000 we have diagnosed 706 new cases of prostatic carcinoma and 454 were clinically localized tumors. The different therapeutic options employed in our series of patients have been: follow-up (FU) (103 patients); radical prostatectomy (RP) (108 patients); radiotherapy without hormonal blockade (RT) (148 patients); and hormonal blockade (HB) (95 patients). We have determined the PFS, the OS and the SS for each group of patients and compared them in patients with different prognostic factors at the time of diagnosis, including age, PSA levels, Gleason's grading and TNM staging. We have also analysed the influence of the tumor progression on the OS. The mean follow-up time has been 5.6 years (range: 0.1-19.2; median: 5.2).

RESULTS

For PFS: the disease progressed in 145 patients (32%) and the PFS at 5 and 10 years has been 77% and 67% for FU; 61% and 50% for RP; 63% and 25% for RT; and 73% and 67% for HB, respectively. The differences between RT and RP were not statistically significant. For the subgroup of patients with PSA levels <10 and Gleason <8 the differences between FU, RP and RT did not reach statistical significance. For OS: 126 patients of our series died (28%) and the OS at 5 and 10 years has been 80% and 61% for FU; 90% and 76% for RP; 85% and 67% for RT; and 64% and 32% for HB, respectively. We have found no significant differences between FU, RP and RT. For SS: 31 patients of our series died of disease (6.8%). The SS at 5 and 10 years has been 100% and 94% for FU; 98% and 98% for RP; 97% and 88% for RT; and 83% and 77% for HB, respectively. We have found no significant differences in the OS between patients with disease progression and without disease progression treated with FU, RP and RT.

CONCLUSIONS

Determination of PSA levels has allowed diagnosis of prostatic carcinomas in early stages of disease; however, our results and those reported in the literature cannot define which is the best therapeutic option in these patients. We should offer the patients individualized information both in the phase of early diagnosis and of therapeutic decisions.

Watchful waiting as a treatment option for localized prostate cancer in the PSA era

The incidence rate of early-stage prostate cancer has dramatically increased since the introduction of the widespread use of PSA testing in developed countries, including Japan. With the downward stage migration there has been much interest in the concept of watchful waiting not only for elderly patients with a life expectancy of less than 10 years but also in younger patients with good social and sexual activity. The results of a recent randomized comparison between radical prostatectomy and watchful waiting for localized disease indicated comparable overall survival but superiority of surgery in disease-specific survival. The predictive value of clinico-pathological parameters including biopsy features and serum PSA seems insufficient to predict tumor growth potential. Our ongoing prospective study is aimed at clarifying whether PSA doubling time assessment for 6 months in patients with favorable biopsy features can be a good indicator for further watchful waiting or immediate aggressive treatment without any survival disadvantage.

Correlation of initial PSA level and biopsy features with PSA-doubling time in early stage prostate cancers in Japanese men

OBJECTIVE

To distinguish good candidates for watchful waiting from those who need immediate treatment in localized prostate cancer.

METHODS

Prostate specific antigen (PSA)-doubling time (DT) was calculated by a log-linear regression model for 78 patients with clinically localized prostate cancer (T1c: 47, T2a: 6, T2b: 21, and T3: 4) under surveillance. Median observation period was 37.5 months. The first 1-year PSA-DT was compared with the overall PSA-DT in 41 patients who had been under surveillance for more than 3 years.

RESULTS

There was significant difference in the PSA-DT distribution between a pooled group of T1c and T2a and a group of T2b and T3 patients (median 58.8 versus 33.3 months, P = 0.0052). A combination of three parameters consisting of initial PSA level less than 10 ng/ml, WHO grade 1, one or two positive core per six to eight systematic biopsy cores with 50% or less cancer involvement significantly correlated with PSA-DT distribution in the T1c plus T2a group (P = 0.0034). The first year assessment of PSA-DT was identical to the overall assessment in 48.8%, 2 years or more in 36.6%, while it was 2 years or less (possibly over-estimated) in 14.6%.

CONCLUSION

PSA-DT can be predictable to some extent with the initial PSA level and biopsy features in early stage prostate cancers. Prospective study is needed to clarify whether temporary observation together with PSA-DT estimation is a safe strategy and is complementary to clinico-pathological parameters at diagnosis.