An analysis of watchful waiting for clinically localized prostate cancer

Understanding prostate cancer

Prostate cancer is the second most common cancer affecting men in Europe and the USA. The incidence of prostate cancer has risen by 60-75% in the Western world in the last 15 years. One in twelve men over the age of 60 develop prostate cancer and this figure is expected to rise to three in twelve in the next 20 years. Early prostate cancer often does not cause symptoms. However, patients may present with lower urinary tract symptoms (LUTS) and therefore, such patients should be investigated. Effective treatment in the form of surgery and radiotherapy is available for individuals with localised disease, and the effectiveness of different combination therapy is being assessed to improve the outcome further.

Approximately 20% of the patients have metastatic disease on presentation. The mainstay of treatment for these patients is androgen ablation therapy; however patients on this regime eventually relapse and develop an androgen independent tumour. This aggressive stage of the disease carries a high morbidity and mortality. At present the treatment for such hormone refractory prostate cancer is inadequate and the desperate search for alternative forms of therapy continues.

Patient perspective on watchful waiting/active surveillance for localized prostate cancer

OBJECTIVE

To describe prostate cancer treatment decision making, focusing on knowledge and attitudes toward observation, known as watchful waiting (WW) or active surveillance (AS), and reasons for not choosing WW/AS.

METHODS

Semistructured in-person interviews were conducted with 21 men (14 black; 7 white) with recently diagnosed localized prostate cancer.

RESULTS

All cancers were detected by prostate-specific antigen screening; 14 men had low-risk disease. Nineteen chose surgery or radiation treatment. The majority wanted to "get rid of" or "cure" the cancer by undergoing aggressive therapy, even with awareness of the potential for significant side effects. Most men seemed unaware of the uncertainty/controversies that aggressive treatment may not cure their cancer or improve their survival. Limited knowledge about WW/AS was common, and few remembered WW/AS being presented as a viable option. Rather, many men perceived it as "doing nothing." Some men, who initially were inclined toward WW/AS, yielded to pressure from family, physicians, or both to choose aggressive treatment. Lack of physician support was a significant barrier to WW/AS.

CONCLUSIONS

The observational strategy (WW/AS) was not viewed as a reasonable approach, even for those with low-risk cancer. The desire for aggressive therapy may reflect the complex psychology associated with receiving a diagnosis of cancer and the limited supportive counseling received. Further efforts to better understand and educate patients and physicians may help men make informed and appropriate treatment decisions to maximize quality of life without compromising survival.

Nomogram to predict insignificant prostate cancer at radical prostatectomy in Korean men: a multi-center study

PURPOSE

Due to the availability of serum prostate specific antigen (PSA) testing, the detection rate of insignificant prostate cancer (IPC) is increasing. To ensure better treatment decisions, we developed a nomogram to predict the probability of IPC.

MATERIALS AND METHODS

The study population consisted of 1,471 patients who were treated at multiple institutions by radical prostatectomy without neoadjuvant therapy from 1995 to 2008. We obtained nonrandom samples of n = 1,031 for nomogram development, leaving n = 440 for nomogram validation. IPC was defined as pathologic organ-confined disease and a tumor volume of 0.5 cc or less without Gleason grade 4 or 5. Multivariate logistic regression model (MLRM) coefficients were used to construct a nomogram to predict IPC from five variables, including serum prostate specific antigen, clinical stage, biopsy Gleason score, positive cores ratio and maximum % of tumor in any core. The performance characteristics were internally validated from 200 bootstrap resamples to reduce overfit bias. External validation was also performed in another cohort.

RESULTS

Overall, 67 (6.5%) patients had a so-called "insignificant" tumor in nomogram development cohort. PSA, clinical stage, biopsy Gleason score, positive core ratio and maximum % of biopsy tumor represented significant predictors of the presence of IPC. The resulting nomogram had excellent discrimination accuracy, with a bootstrapped concordance index of 0.827.

CONCLUSION

Our current nomogram provides sufficiently accurate information in clinical practice that may be useful to patients and clinicians when various treatment options for screen-detected prostate cancer are considered.

Solitary true cyst of pancreas: report of a case and review of literature

CONTEXT

Solitary true cysts of the pancreas in adults are extremely rare, and only few cases have been reported in the literature. The etiology and natural history of these lesions remain unknown, and treatment is not standardized. We describe an additional resected case.

CASE REPORTS

A 55-year-old female who presented to us with a history of heaviness and pain in right upper abdomen for 1 year. CT scan of abdomen showed a large unilocular cyst in the region of the head of the pancreas. The patient underwent pancreatico-duodenectomy with binding pancreaticojejunostomy. The histology of cyst revealed true unilocular pancreatic cyst lined by cuboidal epithelium. She is well after 3 years of follow-up.

CONCLUSIONS

A preoperative work-up alone does not always allow an accurate diagnosis, but it is useful in determining lesion characteristics and guiding therapeutic decision-making. When surgery is indicated, a limited resection is warranted in most cases.

[PSA and follow-up after treatment of prostate cancer]

A first serum total PSA assay is recommended during the first three months after treatment. When PSA is detectable, PSA assay should be repeated three months later to confirm this elevation and to estimate the PSA doubling time (PSADT). In the absence of residual cancer, PSA becomes undetectable by the first month after total prostatectomy: less than 0.1 ng/ml (or less than 0.07 ng/ml) for the ultrasensitive assay method and less than 0.2 ng/ml for the other methods. In the presence of residual cancer, PSA either does not become undetectable or increases after an initial undetectable period. A consensus has been reached to define recurrence as PSA greater than 0.2 ng/ml confirmed on two successive assays. After external beam radiotherapy, PSA can decrease after a mean interval of one to two years to a value less than 1 ng/ml (predictive of recurrence-free survival). Biochemical recurrence after radiotherapy is defined by an increase of PSA by 2 ng or more above the PSA nadir, whether or not it is associated with endocrine therapy. After endocrine therapy, the PSA nadir is correlated with recurrence-free survival. PSA is decreased for a mean of 18 to 24 months followed by a rise in PSA, corresponding to hormone-independence. The time to recurrence or the time to reach the nadir and the PSA doubling time after local therapy with surgery or radiotherapy have a diagnostic value in terms of the site of recurrence, local or metastatic and a prognostic value for survival and response to complementary radiotherapy or endocrine therapy. A PSADT less than eight to 12 months is correlated with a high risk of metastatic recurrence and 10-year mortality. The histological and biochemical characteristics in favour of local recurrence are Gleason score less or equal to seven (3+4), elevation of PSA after a period greater than 12 months and PSADT greater than 10 months. In other cases, recurrence is predominantly metastatic. The risk of demonstrating metastasis in the case of biochemical recurrence after total prostatectomy and before endocrine therapy depends on the PSA level and the PSADT. No consensus has been reached concerning the indication for complementary investigations by bone scan and abdominopelvic CT in patients with biochemical recurrence after treatment of localized cancer without endocrine therapy. However, when PSADT greater than six months, the risk of metastasis is less than 3% even for PSA greater than 30 ng/ml. When PSADT less than six months and PSA greater than 10 ng/ml, the risk of metastasis is close to 50%.

Guidelines and counselling for treatment options in the management of prostate cancer

Prostate cancer is often a complex disease and one in which many aspects of the disease and the affected patient must be taken into consideration before decisions about diagnostic work-up, treatments, follow-up, etc. can be made. The current chapter reflects the current recommendations of the European Prostate Cancer Guideline Group made on the basis of criteria of evidence-based medicine after extensive review of the literature available up to December 2005.

Cystic lesions of the pancreas: an appraisal of an aggressive resectional policy adopted at a single institution during 15 years

BACKGROUND

Although an aggressive resectional approach toward pancreatic cysts has been advocated in the past, many clinicians now deem this therapeutic strategy impractical given the rapidly increasing incidence of incidentally detected pancreatic cystic lesions. The aim of this study was to review the aggressive resectional policy toward pancreatic cysts adopted at our institution during the past 15 years.

METHODS

One hundred nine consecutive patients who underwent surgical resection of a cystic lesion of the pancreas during a 15-year period were retrospectively reviewed. To determine subsets of patients at lower risk of having a malignant cyst, the clinicopathologic features (in particular, the malignant potential) of these patients were compared as a function of 3 variables, ie, presence of symptoms, patient age, and cyst size, using univariate analyses. Results were expressed as median and range and P < .05 was considered statistically significant.

RESULTS

Forty-three (39%) of 109 patients were asymptomatic. Incidental cysts were smaller (28 [10 to 240] vs 59 [10 to 200] mm, P < .001) and were found in older patients (55.0 [18 to 77] vs 45.5 [14 to 82] years, P = .003). Overall, 14% of asymptomatic cysts, versus 35% of symptomatic cysts, were malignant (P = .016). Incidental cysts were also less likely to be premalignant or malignant compared with symptomatic cysts (47% vs 70%, P = .015). Twenty (18%) patients were elderly (73.0 [70 to 82] years old). Elderly patients had a more equal sex distribution (45% vs 76% female, P = .005) and had smaller cysts (26 [10 to 200] vs 55 [10 to 240] mm, P = .003) that involved the head of the pancreas more frequently (8 [40%] vs 17 [19%], P = .045) compared with their younger counterparts. The cohort of elderly patients also had a higher median American Society of Anesthesiologists score (2 [1 to 3] vs 1 [1 to 3], P < .001), and a higher proportion had undergone a "more" major procedure (Whipple's or total pancreatectomy) (55% vs 18%, P < .001). Not unexpectedly, surgical morbidity in the elderly was significantly higher (10 [50%] vs 24 [27%], P = .045). The operative mortality in both groups was not significantly different (1 [5%] vs 1 [1%], P = .324). The proportion of premalignant or malignant lesions in elderly patients was also similar to that in younger patients (11 [55%] vs 55 [62%], P = .574). The size of a cyst in asymptomatic patients had no correlation with its potential for malignancy.

CONCLUSIONS

Reliance on preoperative characteristics alone such as the presence of symptoms, cyst size, and patient age are not sufficiently reliable in determining the malignant potential and thus management approach toward pancreatic cysts.

Prostate cancer in the elderly

Prostate cancer is the second leading cause of cancer deaths among men. Despite earlier diagnosis due to prostate specific antigen (PSA) screening, it is still a disease of the elderly. Diagnosis is based on digital rectal examination (DRE) and PSA assessment. Refinements in PSA testing (age-specific reference ranges, free PSA, PSA density and velocity) increased specificity and limited unnecessary prostate biopsies. Diagnosis in earlier stages (T1 and T2) commonly leads to cure with current treatment modalities. These include radical prostatectomy, external beam radiotherapy and brachytherapy. Other treatment options under development include cryotherapy and high-intensity focused ultrasound. Metastatic prostate cancer is incurable and treatment is based on hormonal therapy. Cytotoxic chemotherapy has only limited role in hormone-independent prostate cancer. Radioisotopes and biphosphonates may alleviate bone pain and prevent osteoporosis and pathological fractures. Follow-up is based on PSA. Prognostic factors for recurrence include stage, Gleason score, pre- and posttreatment PSA. Quality of life issues play an important role in selecting treatment, especially in the elderly due to comorbidities that may negatively affect the overall quality of life. A holistic approach is recommended addressing all quality of life issues without focus only in cancer control.

Radiation therapy in the elderly

The purpose of this review is to highlight aspects of radiation oncology specifically related to aging and caring for the older patient with cancer. Particular emphasis is placed on the preclinical and clinical studies focusing on the efficacy and toxicity of RT in this population. Special techniques are also reviewed that have particular relevance to the treatment of the elderly.

[Selection criteria for the expected management of localised prostate cancer]

Prostate cancer harbours the possibility of overtreatment more than any other malignant disease. Due to its slow growth, expected management is an established therapeutic option in newly diagnosed carcinomas. Improved diagnostic methods and the widespread use of PSA lead to earlier diagnosis of cancers that would not adversely affect the life expectancy of the patient, even when they were left untreated. Several statistical models have been published to identify such insignificant cancers; however, all such nomograms suffer from limited sensitivity and specificity. For the indication of expected management, comorbidity and life expectancy must be considered using risk scores and life tables. In general, expected management is a suitable option for elderly patients with low grade cancers. Young patients and those with intermediate or high-grade cancers are most likely to benefit from active local treatment.

Cancer of the prostate

Prostate carcinoma, with about 190,000 new cases occurring each year (15% of all cancers in men), is the most frequent cancer among men in northern and western Europe. Causes of the disease are essentially unknown, although hormonal factors are involved, and diet may exert an indirect influence; some genes, potentially involved in hereditary prostate cancer (HPC) have been identified. A suspect of prostate cancer may derive from elevated serum prostate-specific antigen (PSA) values and/or a suspicious digital rectal examination (DRE) finding. For a definitive diagnosis, however, a positive prostate biopsy is requested. Treatment strategy is defined according to initial PSA stage, and grade of the disease and age and general conditions of the patient. In localized disease, watchful waiting is indicated as primary option in patients with well or moderately differentiated tumours and a life expectancy <10 years, while radical prostatectomy and radiotherapy (with or without hormone-therapy) could be appropriate choices in the remaining cases. Hormone-therapy is the treatment of choice, combined with radiotherapy, for locally advanced or bulky disease and is effective, but not curative, in 80-85% of the cases of advanced disease. Patients who develop a hormone-refractory prostate cancer disease (HRPC) have to be evaluated for chemotherapy because of the recent demonstration of improved overall survival (2-2.5 months) and quality of life with docetaxel in more than 1,600 cases.

Acute and late complications after radiotherapy for prostate cancer: results of a multicenter randomized trial comparing 68 Gy to 78 Gy

PURPOSE

To compare acute and late gastrointestinal (GI) and genitourinary (GU) side effects in prostate cancer patients randomized to receive 68 Gy or 78 Gy.

METHODS AND MATERIALS

Between June 1997 and February 2003, 669 prostate cancer patients were randomized between radiotherapy with a dose of 68 Gy and 78 Gy, in 2 Gy per fraction and using three-dimensional conformal radiotherapy. All T stages with prostate-specific antigen (PSA) <60 ng/mL were included, except any T1a and well-differentiated T1b-c tumors with PSA < or =4 ng/mL. Stratification was done for four dose-volume groups (according to the risk of seminal vesicles [SV] involvement), age, hormonal treatment (HT), and hospital. The clinical target volume (CTV) consisted of the prostate with or without the SV, depending on the estimated risk of SV invasion. The CTV-planning target volume (PTV) margin was 1 cm for the first 68 Gy and was reduced to 0.5 cm (0 cm toward the rectum) for the last 10 Gy in the 78 Gy arm. Four Dutch hospitals participated in this Phase III trial. Evaluation of acute and late toxicity was based on 658 and 643 patients, respectively. For acute toxicity (<120 days), the Radiation Therapy Oncology Group (RTOG) scoring system was used and the maximum score was reported. Late toxicity (>120 days) was scored according to the slightly adapted RTOG/European Organization for Research and Treatment of Cancer (EORTC) criteria.

RESULTS

The median follow-up time was 31 months. For acute toxicity no significant differences were seen between the two randomization arms. GI toxicity Grade 2 and 3 was reported as the maximum acute toxicity in 44% and 5% of the patients, respectively. For acute GU toxicity, these figures were 41% and 13%. No significant differences between both randomization arms were seen for late GI and GU toxicity, except for rectal bleeding requiring laser treatment or transfusion (p = 0.007) and nocturia (p = 0.05). The 3-year cumulative risk of late RTOG/EORTC GI toxicity grade > or =2 was 23.2% for 68 Gy, and 26.5% for 78 Gy (p = 0.3). The 3-year risks of late RTOG/EORTC GU toxicity grade > or =2 were 28.5% and 30.2% for 68 Gy and 78 Gy, respectively (p = 0.3). Factors related to acute GI toxicity were HT (p < 0.001), a higher dose-volume group (p = 0.01), and pretreatment GI symptoms (p = 0.04). For acute GU toxicity, prognostic factors were: pretreatment GU symptoms (p < 0.001), HT (p = 0.003), and prior transurethral resection of the prostate (TURP) (p = 0.02). A history of abdominal surgery (p < 0.001) and pretreatment GI symptoms (p = 0.001) were associated with a higher incidence of late GI grade > or =2 toxicity, whereas HT (p < 0.001), pretreatment GU symptoms (p < 0.001), and prior TURP (p = 0.006) were prognostic factors for late GU grade > or =2.

CONCLUSIONS

Raising the dose to the prostate from 68 Gy to 78 Gy resulted in higher incidences of acute and late GI and GU toxicity, but these differences were not significant, except for late rectal bleeding requiring treatment and late nocturia. Other factors than the studied dose levels appeared to be important in predicting toxicity after radiotherapy, especially previous surgical interventions (abdominal surgery or TURP), hormonal therapy, and the presence of pretreatment symptoms.

Immediate Versus Deferred Hormonal Treatment for Patients With Prostate Cancer Who Are Not Suitable for Curative Local Treatment: Results of the Randomized Trial SAKK 08/88

Purpose

To determine if immediate hormonal therapy is advantageous compared with deferred treatment in newly diagnosed asymptomatic prostate cancer patients who, for any reason, were not candidates for curative local treatment.

Patients and Methods

Between February 1988 and February 1992, 197 patients with a median age of 76 years (range, 56 to 86 years) were randomly assigned to receive either immediate or deferred orchiectomy on symptomatic progression. The two groups did not differ significantly in clinical or laboratory parameters; 67% had T3-4 tumors and 20% had lymph node metastases. Patient accrual was stopped prematurely because of a similar competing trial. Therefore, observation time was prolonged to achieve the desired number of events and statistical power.

Results

Deferred orchiectomy was necessary in 58% of the patients. Median time to disease progression was 2.8 years less than for patients with immediate orchiectomy. However, overall pain-free time from random assignment to symptomatic progression after immediate or deferred orchiectomy, and performance status, were identical in both groups. Cancer-specific survival tended to be longer in the immediate group (P = .09) but there was no difference in overall survival between the two groups (P = .96). The median hemoglobin value decreased significantly after immediate orchiectomy (P < .001).

Conclusion

For elderly, asymptomatic patients not undergoing curative local treatment, we were unable to show any major advantage of immediate compared with deferred hormonal treatment regarding quality of life or overall survival in our limited number of patients. Disabling complications were prevented in the deferred-treatment arm by careful follow-up; 42% of these patients never required any tumor-specific treatment.

The changing face of low-risk prostate cancer: trends in clinical presentation and primary management

PURPOSE

Early intervention for prostate cancer is associated with excellent long-term survival, but many affected men, especially those with low-risk disease characteristics, might not experience adverse impact to survival or quality of life were treatment deferred. We sought to characterize temporal trends in clinical presentation and primary disease management among patients with low-risk prostate cancer.

METHODS

Data were abstracted from the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a disease registry of 8,685 men with various stages of prostate cancer. Included were 2,078 men who were diagnosed between 1989 and 2001 and had a serum prostate specific antigen

RESULTS

The proportion of patients with low-risk tumor characteristics rose from 29.8% in 1989 to 1992, to 45.3% in 1999 to 2001 (P <.0001). There have been sharp increases in the use of brachytherapy and androgen deprivation monotherapy, from 3.1% and 3.1%, to 12.0% and 21.7%, respectively. Utilization rates for prostatectomy, external-beam radiotherapy, and observation have fallen accordingly, from 63.8%, 16.1%, and 13.8%, to 51.6%, 6.8%, and 7.9% (P <.0001 for all except prostatectomy [P =.0019]). Age and socioeconomic status were significantly associated with treatment selection, but overall, the treatment trends were echoed on subgroup analysis of patients 75 years or older.

CONCLUSION

Low-risk features characterize a growing proportion of prostate cancer patients, and there have been significant shifts in the management of low-risk disease. Overtreatment may be a growing problem, especially among older patients.

Collapse

Key Words Collapse

MESH Headings

• Aged
• Aged, 80 and over
• Decision Making
• Disease Progression
• Disease-Free Survival
• Humans
• Male
• Middle Aged
• Multivariate Analysis
• Prostate-Specific Antigen/blood
• Prostatic Neoplasms/diagnosis
• Prostatic Neoplasms/mortality
• Prostatic Neoplasms/therapy
• Quality of Life
• Risk Assessment
• Risk Factors
• Socioeconomic Factors
• Statistics, Nonparametric
• United States/epidemiology

Collapse

Grants

• P50 CA089520 NCI NIH HHS
• P50 CA089520-05 NCI NIH HHS
• P50 C89520 PHS HHS

Collapse

Affiliation(s)

Matthew R. Cooperberg Dept. of Urology, Program in Urologic Oncology, Urologic Outcomes Research Group, UCSF/Mt. Zion Comprehensive Cancer Center, University of California, San Francisco, CA
Deborah P. Lubeck Dept. of Urology, Program in Urologic Oncology, Urologic Outcomes Research Group, UCSF/Mt. Zion Comprehensive Cancer Center, University of California, San Francisco, CA
Maxwell V. Meng Dept. of Urology, Program in Urologic Oncology, Urologic Outcomes Research Group, UCSF/Mt. Zion Comprehensive Cancer Center, University of California, San Francisco, CA
Shilpa S. Mehta TAP Pharmaceutical Products, Inc., Lake Forest, IL
Peter R. Carroll Dept. of Urology, Program in Urologic Oncology, Urologic Outcomes Research Group, UCSF/Mt. Zion Comprehensive Cancer Center, University of California, San Francisco, CA

Collapse

THE CONTEMPORARY MANAGEMENT OF PROSTATE CANCER IN THE UNITED STATES: LESSONS FROM THE CANCER OF THE PROSTATE STRATEGIC UROLOGIC RESEARCH ENDEAVOR (CAPSURE), A NATIONAL DISEASE REGISTRY

PURPOSE

The epidemiology and treatment of prostate cancer have changed dramatically in the prostate specific antigen era. A large disease registry facilitates the longitudinal observation of trends in disease presentation, management and outcomes.

MATERIALS AND METHODS

The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) is a national disease registry of more than 10000 men with prostate cancer accrued at 31 primarily community based sites across the United States. Demographic, clinical, quality of life and resource use variables are collected on each patient. We reviewed key findings from the data base in the last 8 years in the areas of disease management trends, and oncological and quality of life outcomes.

RESULTS

Prostate cancer is increasingly diagnosed with low risk clinical characteristics. With time patients have become less likely to receive pretreatment imaging tests, less likely to pursue watchful waiting and more likely to receive brachytherapy or hormonal therapy. Relatively few patients treated with radical prostatectomy in the database are under graded or under staged before surgery, whereas the surgical margin rate is comparable to that in academic series. CaPSURE data confirm the usefulness of percent positive biopsies in risk assessment and they have further been used to validate multiple preoperative nomograms. CaPSURE results strongly affirm the necessity of patient reported quality of life assessment. Multiple studies have compared the quality of life impact of various treatment options, particularly in terms of urinary and sexual function, and bother.

CONCLUSIONS

The presentation and management of prostate cancer have changed substantially in the last decade. CaPSURE will continue to track these trends as well as oncological and quality of life outcomes, and will continue to be an invaluable resource for the study of prostate cancer at the national level.

Watchful Waiting and Factors Predictive of Secondary Treatment of Localized Prostate Cancer

PURPOSE

Watchful waiting remains an important treatment option for some patients with localized prostate cancer. We defined the demographic, clinical and outcome features of men selecting watchful waiting as an initial treatment strategy, and determined factors predictive of eventual progression to secondary treatment.

MATERIALS AND METHODS

Of 8390 patients diagnosed with prostate cancer from 1990 to 2001 in the Department of Defense Center for Prostate Disease Research Database, 1158 patients chose watchful waiting as initial treatment. The demographic and clinical differences between patients on watchful waiting and those choosing other initial treatments were compared using the chi-square test. Secondary treatment-free survival according to various prognostic factors was plotted using the Kaplan-Meier method and differences were tested using the log rank test. A multivariate Cox proportional hazards regression analysis was performed to determine which factors were independent predictors of secondary treatment.

RESULTS

Compared to other patients, those selecting watchful waiting were older, had lower prostate specific antigen (PSA) at diagnosis, and were more likely to have lower stage (cT1) and lower grade (Gleason sum 7 or less) cancers. Age, PSA and clinical stage were all significant and independent predictors of secondary treatment. The relative risk of secondary treatment can be expressed as EXP (-0.034 x age at diagnosis + 0.284 x LOG (diagnostic PSA) + 0.271 x clinical stage T2 + 0.264 x clinical stage T3).

CONCLUSIONS

Men who elect watchful waiting as initial management for prostate cancer are older with lower Gleason sums and serum PSA. In these men, age at diagnosis, serum PSA and clinical stage are the most significant predictors of requiring or selecting secondary treatment.

Temporarily Deferred Therapy (watchful waiting) for Men Younger Than 70 Years and With Low-Risk Localized Prostate Cancer in the Prostate-Specific Antigen Era

Purpose: Watchful waiting (WW) is an acceptable strategy for managing prostate cancer (PC) in older men. Prostate-specific antigen (PSA) testing has resulted in a stage migration, with diagnoses made in younger men. An analysis of the Department of Defense Center for Prostate Disease Research Database was undertaken to document younger men with low- or intermediate-grade PC who initially chose WW.

Patients and Methods: We identified men choosing WW who were diagnosed between January 1991 and January 2002, were 70 years or younger, had a Gleason score ≤ 6 with no Gleason pattern 4, had no more than three positive cores on biopsy, and whose clinical stage was ≤ T2 and PSA level was ≤ 20. We analyzed their likelihood of remaining on WW, the factors associated with secondary treatment, and the influence of comorbidities.

Results: Three hundred thirteen men were identified. Median follow-up time was 3.8 years. Median age was65.4 years (range, 41 to 70 years). Ninety-eight patients remained on WW; 215 proceeded to treatment. A total of 57.3% and 73.2% chose treatment within the first 2 and 4 years, respectively. Median PSA doubling time (DT) was 2.5 years for those who underwent therapy; those remaining on WW had a median DT of 25.8 years. The type of secondary treatment was associated with the number of patient’s comorbidities (P = .012).

Conclusion: Younger patients who choose WW seemed more likely to receive secondary treatment than older patients. PSA DTs often predict the use of secondary treatment. The number of comorbidities a patient has influences the type of secondary therapy chosen. The WW strategy may better be termed temporarily deferred therapy.

Time Trends and Characteristics of Men Choosing Watchful Waiting for Initial Treatment of Localized Prostate Cancer: Results From CaPSURE

PURPOSE

Watchful waiting (WW) is one option for men with clinically localized prostate cancer. We examined temporal trends in the use of WW, as well as sociodemographic and clinical profiles of men who choose this form of management.

MATERIALS AND METHODS

The Cancer of the Prostate Strategic Urologic Research Endeavor is a national registry of patients with various stages of prostate cancer. Between 1989 and 2000, 5,365 men in the database were diagnosed with localized disease and elected either WW or active treatment within 9 months of diagnosis. Of these men 402 elected WW as initial disease management. We analyzed time trends in WW use, and sociodemographic and clinical predictors of WW using chi-square tests and multivariate logistical regression.

RESULTS

In examining 3-year intervals, use of WW increased from 7.5% in 1989 to 1991 to 9.5% in 1992 to 1994, and then decreased during the next 6 years to 5.5% in 1998 to 2000 (p = 0.001). With time there was a significant increase in the proportion of WW patients with T1 disease and prostate specific antigen of 10 ng/ml or less. Compared to patients choosing active treatment, patients opting for WW were more likely to have low risk disease. After controlling for clinical factors WW patients were also more likely to be 75 years old or older, to have Medicare insurance and to have greater comorbidity.

CONCLUSIONS

During the prostate specific antigen era rates of WW for the initial treatment of prostate cancer have been decreasing despite considerable downward stage migration. We expect that as prostate cancer risk assessment and surveillance strategies continue to improve, more patients may benefit from this approach to management.

External beam radiotherapy in elderly patients with clinically localized prostate adenocarcinoma: age is not a problem

The files of 183 elderly patients aged >70 years, with localized prostate cancer (T1-3, N0-X, M0), treated with radical external radiation therapy (ERT) from January 1992 to December 2001 at the Radiotherapy Department of the Istituto Nazionale Tumori of Milan, were reviewed. Median age was 75 years. ERT represented the sole treatment for 73 patients (39.9%); in 110 cases (60.1%) hormonal therapy (HT) was associated with neoadjuvant intent. Five-year overall, disease-specific and biochemical NED (bNED) survival rates were 90.2, 93.7 and 63.2%, respectively. A subset of 23 patients aged 80 years and over were analyzed and compared to 160 men aged 70-79 years. Acute toxicity and late complications were analyzed in the two groups of patients according to the RTOG scoring system. Only 10 patients (5.4%) showed grades 2-3 (G2-3) late sequelae. The results obtained in this single-institute series highlight the pivotal role of ERT in the management of clinically localized prostate cancer in the elderly.

Insignificant prostate cancer in radical prostatectomy specimen: time trends and preoperative prediction

OBJECTIVES

We analysed systematically a consecutive series of radical prostatectomy specimens performed between January 1992 and June 2002 with emphasis to time trends, tumour characteristics and preoperative prediction of insignificant prostate cancers (cancer volume < or =0.5 cm(3) and Gleason pattern < or =6).

METHODS

In a total of 1254 patients, prostate cancers (PC) were divided by a cancer volume of 0.5 cm(3). The two groups were compared in their clinical and pathological tumour characteristics. Correlation was determined between yearly incidence rates of T1c and insignificant PC. Furthermore, a logistic regression analysis was performed to calculate the ability to predict insignificant PC and a statistical model was established.

RESULTS

Overall, 73 (5.8%) of 1254 men presented with insignificant PC. The incidence of insignificant PC showed no significant linear correlation with that of T1c PC (p<0.61). PSA density and percentage of cancer per biopsy set were assessed as independent prognosticators predicting insignificant PC. Using a threshold of 1% of cancer per biopsy set and a PSA density < or =0.10, positive and negative predictive values were 45.0% and 93.3%, respectively.

CONCLUSION

In our series, only few men undergoing radical prostatectomy were affected by insignificant PC. Their incidence showed no statistically significant correlation with that of T1c tumours. Furthermore, insignificant PC was predictable by PSA density and percentage of cancer per biopsy set. Mainly elderly patients facing different treatment options for localized PC may benefit from this information.

[Clinical and biological progression of incidental prostatic cancer ( Stage T 1a)]

OBJECTIVES

To analyze the biological and clinical progression of the prostate cancer stage T1a.

MATERIAL AND METHODS

Retrospective study of 44 patients diagnosed of T1a prostate carcinoma between 1985 and 2001. We value biological and clinical progression, time up to the progression, mortality for tumour reason and survival, with the following stratification: patients without initial treatment and patients treated by means of external radiotherapy or radical prostatectomía.

RESULTS

Of all 44 patients biological progression was observed in 5 (11.36%) and clinical progression in 4 (9.09%). The mortality to 5 years for tumour reason was of 2 (4.54%). Of all 38 patients without initial treatment biological progression was observed in 5 (13.15%), in an average time of 25.8 months and clinical progression in 4 (10.52%), in an average time of 34.5 months. The mortality to 5 years was of 2 (5.26%). In all 6 patients to whom radical treatment carried out them progression was not observed and they all live. There are no statistically significant differences between both groups of patients (p = NS).

CONCLUSIONS

The biological and clinical progression of the T1a prostate cancer is low, 11.36% and 9.09%, respectively. The mortality to 5 years is of 4.54%. Differences of survival do not exist, statistically significant, between treated and not treated.

Information on video format can help patients with localised prostate cancer to be partners in decision making

A video was produced to inform men diagnosed with localised prostate cancer of the different management options for their disease. It was tested for increased knowledge and understanding on a healthy population of similar age (n=10), who were assessed before and after watching the video (20 interviews). The video was then shown to 12 men who had been diagnosed with prostate cancer but had not started any treatment for their disease (24 interviews). Interviews among the healthy cohort revealed not only the lack of knowledge of anatomy and physiology but also the way in which these men used past experiences to help explain and remember complex medical procedures. The patients focused on the treatments and outcomes, remembering less of the technicalities. All men interviewed vividly remembered the patients participating in the video; they drew inferences and developed affinity towards specific individuals. Both groups felt that video provided information in a user friendly way. Although remembering few anatomical terms all participants described a visual image that led to a perception of understanding rather than a definitive increase in knowledge. Patients, however, felt they had a clearer understanding of the disease and its treatment, and therefore better able to be active informed partners in the decision-making process.

Early prostate cancer: is there a need for new treatment options?

Improvements in diagnostic techniques have led to prostate cancer being diagnosed in younger patients and at an earlier stage of disease. The question therefore arises as to what is the best treatment for early prostate cancer. The main issues to be considered are whether the cancer is likely to progress quicker if these patients do not receive early treatment and what the quality of life implications are for patients receiving early treatment. As yet, due to the lack of valid comparisons of treatments, there is no clear "best treatment" for early prostate cancer. A number of clinical trials, comparing current treatments or investigating potential new treatment options for early prostate cancer, are in progress. The results of these should clarify the relative benefits of currently available treatments. This article reviews the latest information on the incidence, prognosis and current treatments for early prostate cancer and discusses the need for new treatments. Potential clinical benefits and cost implications of new treatments for early prostate cancer, such as improved surgical and radiotherapy techniques and adjuvant medical therapy, are also evaluated.

An evaluation of bicalutamide in the treatment of prostate cancer

Prostate cancer is a major health problem in men, causing significant morbidity and mortality. Although traditionally considered a disease of old age, improved diagnostic techniques have resulted in earlier diagnosis and many men are now treated while still physically and sexually active. Current therapies for prostate cancer, which include medical or surgical castration, have a significant impact on many aspects of quality of life. The non-steroidal antiandrogen bicalutamide (Casodex, AstraZeneca) has a favourable tolerability profile with demonstrated efficacy in several stages of prostate cancer and represents an alternative therapeutic strategy to castration. Mature survival data from men with previously untreated, locally-advanced disease reveal that bicalutamide monotherapy provides survival benefits that do not differ significantly from castration, while offering important advantages with respect to the maintenance of physical capacity and sexual interest. Recent data from a prospective randomised trial, the largest prostate cancer treatment study ever conducted, demonstrate that immediate therapy with bicalutamide (alone or as an adjuvant to therapy of curative intent) significantly reduces the risk of objective disease progression in patients with localised or locally-advanced prostate cancer. Antiandrogens are also used in combination with castration (combined androgen blockade) for advanced disease. Another large, randomised trial demonstrated that combined androgen blockade with bicalutamide is associated with a similar survival outcome to combined androgen blockade with flutamide and is better tolerated. The evidence reviewed demonstrates that bicalutamide currently has a favourable risk:benefit ratio in several stages of prostate cancer. The role of bicalutamide will be further defined by ongoing studies.

Is 'watchful waiting' a real choice for men with prostate cancer? A qualitative study

OBJECTIVE

To understand what leads men to choose 'watchful waiting' rather than active treatment for cancer of the prostate.

PATIENTS AND METHODS

Fifty men with confirmed prostate cancer in England, Wales and Scotland were interviewed about all aspects of their illness, for a Database of Individual Patients' Experience of illness. The sample included men at different stages of diagnosis and with experience of a wide range of treatments. We report here only what men said about their choice of treatment and the decision-making process.

RESULTS

Watchful waiting would have been clinically inappropriate for almost half of the men (those with serious urinary symptoms and those with metastatic disease). However, few of the men who might have chosen watchful-waiting remembered this being presented as a serious option. Most in this group chose radical prostatectomy, radiotherapy, brachytherapy or cryosurgery. The few who chose watchful waiting had found doctors who supported their decision, had assessed the evidence from Internet sites, and were concerned about the side-effects and uncertain outcome of treatment. Men who chose watchful waiting, as well as those who opted for treatment, described considerable pressure from family members, doctors or support groups, to seek active treatment.

CONCLUSION

This study helps to explain why some men will not contemplate watchful waiting, and why others may find it difficult to pursue that option. Understanding men's concerns may help clinicians to support men's treatment decisions. Treatment for prostate cancer is highly controversial because no randomized, controlled trials have shown whether or not active intervention increases survival. If trials are not completed it cannot be determined whether active treatments are the best course of action for men with prostate cancer.

Prediction of pelvic lymph node metastasis by the ratio of cathepsin B to stefin A in patients with prostate carcinoma

BACKGROUND

Pathologic grade and/or histologic score, extraprostatic extension indicated by invasion of the prostatic capsule, margin, and/or seminal vesicles by prostate cancer cells, serum total prostate-specific antigen (PSA), free PSA, complexed PSA levels and/or their ratios, regional pelvic lymph node metastases, and clinical staging have been used to diagnose and monitor the treatment of prostate carcinoma (PC) patients. The Gleason grading system is also used to grade/score a patient's stage of disease, with lower to higher scores indicating progression of PC. However, Gleason's system cannot be used to distinguish biologically aggressive PCs within a single Gleason score. Our objective was to identify subpopulations (or clones) of aggressive prostate cancers within an individual Gleason score by utilizing biological molecule(s) that also facilitate cancer cell invasion to prostatic stroma and metastasis to the lymph nodes.

MATERIALS AND METHODS

Specimens were collected from 97 patients with PC and from 8 patients with benign prostatic hyperplasia. These patients had not been treated with hormonal and/or chemotherapeutic agents before undergoing a prostatectomy at the Minneapolis Veterans Affairs Medical Center. Formalin-fixed, paraffin or paraplast-embedded prostate tissue sections were stained with hematoxylin and eosin for pathologic diagnosis and adjacent sections were stained for for immunohistochemical study. We also collected data on age, race, extraprostatic extension, margin status, seminal vesicle, and lymph node invasion by cancer cells, clinical stage at prostatectomy, and mortality/survival data, including the available presurgery and postsurgery serum total PSA and prostatic acid phosphatase concentrations in patients. Immunohistochemical localization of mouse or rabbit anti-cathepsin B (CB) antibody IgG and mouse antihuman stefin (cystatin) A IgG was quantified using a computer-based image analysis system equipped with Metamorph software.

RESULTS

CB and stefin A identified aggressive and less aggressive clones of PCs within an individual Gleason score. Tumors with a Gleason Score of 6 that are similar histologically and morphologically were heterogeneous with respect to the ratios of CB to stefin A (CB > stefin A, CB = stefin A, and CB < stefin A). We also found a significant positive association (P = 0.0066) between ratios of CB and stefin A (CB > stefin A) and the incidence of pelvic lymph node metastases, but not with ratios of CB less than stefin A and/or ratios of CB equal to stefin A. Patients with Gleason 7 PCs had a higher incidence of positive lymph nodes than those with Gleason Score 6 tumors. Our data indicated that mortality rates increased in patients when the ratios of CB were greater than stefin A.

CONCLUSIONS

PC within an individual Gleason score is a heterogeneous tumor that contains clones or subpopulations of aggressive and less aggressive tumors that can be defined by the ratios of CB to stefin A. PC with an aggressive clone can be identified when the ratio of CB is greater than that of stefin A. Less aggressive clones are identified when the ratio of CB is less than that of stefin A or when the ratio of CB is equal to that of stefin A. The ratios of CB to stefin A can be used in the differential diagnosis and treatment of patients with PC. This is the first report to identify phenotypes of aggressive and less aggressive PCs within a Gleason score.

Quality of life studies and genito-urinary tumors

BACKGROUND

Genitourinary (GU) tumors represent a large proportion of solid cancers (1 of 4) and a wide variety of natural histories, based on various prognostic factors and resulting in different treatment options and end points. In some cases, for the same stage of disease, different treatment strategies do not impact differently on overall survival (OS): surgery vs. radiation, or radical vs. conservative multidisciplinary approach, adjuvant or neoadjuvant, chemotherapy vs. BSC. Quality of life (QoL) is considered a reasonable end point when differences in OS do not seem to be striking.

DESIGN

A review of the literature on different disease stages was undertaken to show where and when QoL was used as the end point of treatment efficacy.

RESULTS

Very few studies have been performed in prostate, bladder and testicular cancer to show the impact of different treatment approaches on QoL. Although these studies might be considered as non-conclusive, some data may allow a better choice for the patients.

CONCLUSIONS

QoL as the principal end point has not been used in clinical trials of GU tumors comparing different treatment approaches. This makes the choice between treatments offering similar survival but different toxicity patterns, body and behavioral consequences more difficult. We suggest that future prospective randomized studies should be planned taking into account the QoL as the main end point.

Prostate cancer and selenium

The important progress achieved in the treatment of prostate cancer comes by exacting significant costs [11, 16-18, 20, 23, 25]. Currently, there is incomplete evidence that the radical interventions at hand significantly reduce the human costs of the disease. Surgery and radiotherapy induce substantial risks of incontinence and impotence. The PSA test has probably decreased the stage at which prostate cancer is diagnosed [15]. Nonetheless, the PSA is a means of earlier detection; it does not elucidate quantitatively distinct modes of treatment. The PSA test is not a means of prostate cancer prevention. The continuing incidence, morbidity, and mortality imposed by this disease strongly indicate that preventive strategies for its control are necessary. Chemoprevention with selenium and other agents offers a promising approach that is undergoing intensive investigation. Randomized trials underway at the authors' center are building on the important clinical trial results reported by Dr. Larry C. Clark. These studies will evaluate the activity of selenium at several points along a continuum ranging from cancerous prostatic tissue in men with diagnosed cancer to premalignant tissue in men with high-grade PIN to healthy tissue in high-risk men with negative biopsy to long-term effects on cancerous tissue in men with frank cancer. These trials will also offer an opportunity for preliminary evaluation of the mechanisms by which selenium treatment could result in the slower development or progression of prostate cancer.

The role of volume-weighted mean nuclear volume in predicting tumour biology and clinical behaviour in patients with prostate cancer undergoing watchful waiting

OBJECTIVE

To investigate whether the volume-weighted mean nuclear volume (MNV, the only means by which unbiased estimates of three-dimensional variables can be obtained from a two-dimensional section by stereological methods) at diagnosis correlates with tumour biology and clinical behaviour in patients with prostate cancer treated by watchful waiting.

PATIENTS AND METHODS

In a prognostic study, 64 patients with clinically localized prostate cancer were followed prospectively with initial expectant management. The median (mean, range) follow-up was 22 (27, 6.0-68) months. The prostate specific antigen (PSA) doubling time (PSADT) was calculated by linear regression. The MNV was estimated using biopsy specimens, based on a stereological method, and compared with PSADT and traditional clinicopathological variables.

RESULTS

PSADT was significantly associated with MNV, but not with other clinicopathological variables. The PSA 'rapid-riser' subset (PSADT<median value) had significantly larger MNVs than did the PSA 'slow-riser' (PSADT>or=median value) and PSA-stable subsets (P = 0.0017 and 0.004, respectively). On multivariate analysis using a stepwise Cox proportional hazards regression, only MNV remained independently significant as a predictor of clinical progression among the clinicopathological variables (P < 0.001).

CONCLUSIONS

These findings suggest that cancer cell nuclear volume is significantly associated with tumour biology and behaviour in patients with prostate cancer. Although further study with a larger patient population is needed to confirm the findings, estimates of MNV may be an important prognostic indicator in men treated with watchful waiting.

Expectant management of prostate cancer

OBJECTIVES

To discuss the role of expectant management in the treatment of clinically localized prostate cancer.

DATA SOURCES

Published research and review articles, textbooks, and pending research publications.

CONCLUSIONS

Expectant management is a viable option for the treatment of clinically localized prostate cancer in carefully selected men.

IMPLICATIONS FOR NURSING PRACTICE

Nursing personnel along with physicians must work together to develop coping strategies for these men to deal with the continual uncertainty of this treatment program.

The bicalutamide Early Prostate Cancer Program. Demography

BACKGROUND: The optimal treatment for early prostate cancer has yet to be established. A well-tolerated hormonal therapy such as bicalutamide could be a useful treatment option in this setting, either as adjuvant or immediate therapy. A major collaborative clinical trials program was set up to investigate bicalutamide as a treatment option for local prostate cancer (localized or locally advanced disease). METHODS: The bicalutamide Early Prostate Cancer program comprises three randomized, double-blind, placebo-controlled trials of similar design that are being conducted in distinct geographical areas (North America; Australia, Europe, Israel, South Africa and Mexico; and Scandinavia). Men with T1b-4N0-1M0 (TNM 1997) prostate cancer have been randomized on a 1:1 basis to receive bicalutamide 150 mg daily or placebo. Recruitment to the program closed in July 1998, and follow-up is ongoing. Study endpoints include time to clinical progression, overall survival and tolerability. RESULTS: 8113 men aged 38 to 93 years (mean 66.9) were randomized over a 3-year period. 67.4% of the enrolled patients had localized disease (T1-2) and 66.4% had a Gleason score </=6 at study entry, while the majority of patients had node-negative (N0) disease; only 3.1% in two of the studies and none in the third study had confirmed N+ disease. Overall, 71.8% of the patients received therapy of primary curative intent within 16 weeks of randomization; the remainder received watchful waiting as their primary approach. Across the program, the two randomized groups are well balanced. CONCLUSION: This is the largest randomized clinical trial program to date in local prostate cancer and is expected to provide critical information on the role of bicalutamide as an addition to standard care for patients with local prostate cancer who have received a therapy of curative intent or are candidates for watchful waiting.

Observation in the management of localized prostate cancer

Background

The widespread use of the prostate-specific antigen test, the availability of ultrasound, and improved techniques for prostate biopsy have led to the diagnosis of organ-confined prostate cancers at an earlier stage. An unknown number of these cancers will be incidental and will not impact the patient's quality or length of life.

Methods

The most recent published reports and decision analysis studies on observation management were reviewed. We also analyzed our own series of observed patients.

Results

Three contemporary series on observation and three reports on decision analysis for treatment of early prostate cancer define a group of patients who may be treated with observation. Our own preliminary experience, however, demonstrates that a significant number undergo definitive treatment within 3 years from diagnosis. The optimal treatment for men with early prostate cancer is currently unknown.

Conclusions

A subset of patients with newly diagnosed prostate cancer may be managed by observation. Standard protocols for selection and follow-up of patients on observation need to be developed.

Treatment decisions for localized prostate cancer: asking men what's important

OBJECTIVE

To identify what factors men consider important when choosing treatment for prostate cancer, and to assess why men reject watchful waiting as a treatment option.

PARTICIPANTS

One hundred two consecutive men with newly diagnosed localized prostate cancer identified from hospital and community-based urology practice groups.

MEASUREMENTS

Patients were asked open-ended questions about likes and dislikes of all treatments considered, how they chose their treatment, and reasons for rejecting watchful waiting. The interviews were conducted in person, after the men had made a treatment decision but before they received the treatment.

MAIN RESULTS

The most common reasons for liking a treatment were removal of tumor for radical prostatectomy (RP) (n = 15), evidence for external beam radiation (EBRT) (n = 6), and short duration of therapy for brachytherapy (seeds) (n = 25). The most frequently cited dislikes were high risk of incontinence for RP (n = 46), long duration of therapy for EBRT (n = 29), and lack of evidence for seeds (n = 16). Only 12 men chose watchful waiting. Fear of future consequences, cited by 64% (n = 90) of men, was the most common reason to reject watchful waiting.

CONCLUSION

In discussing treatment options for localized prostate cancer, clinicians, including primary care providers, should recognize that patients' decisions are often based on specific beliefs regarding each therapy's intrinsic characteristics, supporting evidence, or pattern of complications. Even if patients do not recall a physician recommendation against watchful waiting, this option may not be chosen because of fear of future consequences.

Deferred treatment of localized prostate cancer in the elderly: the impact of the age and stage at the time of diagnosis on the treatment decision

OBJECTIVE

To assess the clinical behaviour of clinically localized prostate cancer in elderly patients monitored until progression, and the impact of clinical variables, i.e. clinical stage, Gleason score, the dynamics of prostate specific antigen (PSA) and age, on the natural history of the disease.

PATIENTS AND METHODS

Between February 1991 and January 1998, 54 patients (mean age 76.4 years, median 77 at the time of diagnosis) with clinically localized prostate cancer who elected for watchful waiting were identified. They were monitored regularly and treatment deferred until progression. Progression was defined as local stage progression (as assessed on a digital rectal examination), biochemical progression or metastasis. All patients who progressed were offered either radiation therapy or hormonal treatment. Each clinical variable was assessed by univariate and multivariate analysis to predict disease progression. The mean follow-up was 47 months.

RESULTS

Of the 54 patients, 28 (52%) progressed; 10 had biochemical, 11 local and four biochemical and local progression, and three developed metastasis. All the patients who progressed elected to receive hormonal treatment. The mean time to progression was 35 months. Gleason score (</= 6 and > 6), age (</= 75 and > 75 years) and serum PSA level (</= 10 and > 10 ng/mL) were statistically significant predictors of disease progression (P = 0.04, < 0.001 and 0.02, respectively). The clinical stage at the time of diagnosis had a borderline effect on disease progression (P = 0.06). On multivariate analysis, Gleason score and PSA level were statistically significant predictors of disease progression.

CONCLUSION

These results suggest that the treatment of prostate cancer should not be deferred in patients aged > 75 years with a good performance status when the biopsy has a Gleason score >/= 6 and the serum PSA level is >/= 10 ng/mL.

Prostate cancer

Prostate cancer is the second leading cause of cancer death in men. Recommendations for screening and treatment are usually made, especially in the popular press, without regard to patient age or medical health. This article focuses on the trade-off between the benefits and side effects of screening and treatment.