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Watchful Waiting for Prostate Cancer 


Observation
(surveillance or conservative management) of prostate cancer.

Because prostate cancer may progress very slowly and since many of the men are elderly, a case can be made to simply follow the patient and monitor his disease and not treat him at all, unless the cancer clearly starts to progress. (This is referred to as watchful waiting.) This decision would be based on a patient's age (life expectancy, see life expectancy tables.) and how aggressive (i.e. Gleason score or advanced stage) the cancer is.

A Scandanavian trial compared surgery with no treatment and found significantly less cancer deaths in the treated group but and in overall survival (see study.) A similar study comparing no initial therapy with immediate hormonal therapy also found less cancer deaths in the early treated but overall survival the same (see study).

Another recent study from Sweden of men with untreated prostate cancer showed cancer deaths were primarily in the more aggressive grade cancers (see graph) and that after 15 years many cancer became more aggressive (see graph.) A study from Hopkins showed little risk of waiting in low risk patients (go here.) A large study showed a survival advantage for treatment even in older men (see graph).

 
The Gleason Score is critical in deciding whether any treatment is necessary. In an elderly patient with a slow growing cancer (Gleason score of 2 or 3) simple observation (called conservative therapy) may be appropriate. Untreated patients with high (fast growing) Gleason cancers are more likely to die from the prostate cancer than slow growing cancers (see graph.) A recent study (JAMA 1998;280:975) in men aged 55 to 74 who did not receive active therapy for their prostate cancer, looked at the odds of dying of cancer in 15 years based on their Gleason score as noted: (see survival graphs for Gleason 2-5 or Gleason 6 - 7 or Gleason 8 - 10. They updated these graphs in 2010, go here for moderate grade and here for high grade. There may be even better methods to determine which cancers are likley to behave more aggressively (e.g. Prostate PX).

Untreated Prostate Cancer
Gleason Score Death by 15 Years
2 - 4 4 - 7%
5 6 - 11%
6 18 - 30%
7 42 - 70%
8-10 60 - 87%
They recently updated the study with 20 year follow up as noted:

20-Year Outcomes Following Conservative Management of Clinically Localized Prostate Cancer

Peter C. Albertsen, MD, MS; James A. Hanley, PhD; Judith Fine, BA  JAMA. 2005;293:2095-2101.

The prostate cancer mortality rate was 33 per 1000 person-years during the first 15 years of follow-up  and 18 per 1000 person-years after 15 years of follow-up (95% CI, 10-29). The mortality rates for these 2 follow-up periods were not statistically different, after adjusting for differences in tumor histology. Men with low-grade prostate cancers have a minimal risk of dying from prostate cancer during 20 years of follow-up (Gleason score of 2-4, 6 deaths per 1000 person-years). Men with high-grade prostate cancers have a high probability of dying from prostate cancer within 10 years of diagnosis (Gleason score of 8-10, 121 deaths per 1000 person-years; ). Men with Gleason score of 5 or 6 tumors have an intermediate risk of prostate cancer death. Gleason 2- 5 , Gleason 6 - 7, Gleason 8 - 10.