Does Overdiagnosis Lead To Overtreatment Of Older Men
The widespread use of PSA screening has led to an increase in the diagnosis and treatment of early localized prostate cancer. Data from the US Cancer of the Prostate Strategic Urological Research Endeavor database suggest a significant decrease in risk in the last 2 decades in the United States, with more patients being identified with low-risk disease at diagnosis, but the role of active treatment of low- and intermediate-risk disease in elderly men remains controversial.
The median time from diagnosis to death from prostate cancer for men with nonpalpable disease is approximately 17 years., Considering that the US male life expectancy at the age of 65 years is 16 years, aggressive therapy will hardly extend life expectancy of older men with no palpable prostate cancer at the time of diagnosis. Twenty to 30% of prostate cancers detected by PSA screening programs show Gleason scores of 6 or lower and, thus, are not poorly differentiated and have volumes smaller than 0.5 cm3.
Histologic evaluation of radical prostatectomy specimens demonstrated that about 20% to 30% of cancers are small volume, show low Gleason scores, and are consequently clinically harmless., Many of these cancers pose little threat to life, especially for older men. Has PSA screening resulted in prostate cancer overdiagnosis?
The Future Of Active Surveillance
While confidence in conservative management for low-risk disease has increased significantly as the cohorts have matured, many unanswered questions remain. These include the following:
What are the molecular events that signal progression of low-grade disease?
How can we optimally identify the wolves in sheeps clothing-ie, those low-grade cases that harbor higher-grade cancer?
What is the effect of germline genetic alterations-eg, BRCA1/2 mutations-on eligibility for surveillance?
How should multiparametric MRI and biomarkers be integrated into treatment decision making?
Which intermediate-risk patients are candidates for surveillance?
What interventions are able to reduce the risk of biological progression in men on active surveillance, and thus are warranted?
What is the most efficient and cost-effective way to follow patients longitudinally? Is serial biopsy still required, and in whom?
Can risk stratification allow some patients to minimize the burden of follow-up?
Can the widespread adoption of surveillance for low-risk disease rehabilitate prostate cancer screening?
General Prostate Cancer Survival Rate
According to the American Cancer Society:
- The relative 5-year survival rate is nearly 100%
- The relative 10-year survival rate is 98%
- The 15-year relative survival rate is 91%
Note: Relative survival rate means the percentage of patients who live amount of years after their initial diagnosis.
Keep in mind, however, that because the compiled list figures are of cancers diagnosed up to 15 years ago, you may have an even greater chance of survival than these indicate due to advances in prostate cancer treatment technology
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Outlook For Men With Advanced Prostate Cancer
While it isnt possible to cure advanced prostate cancer, treatments can help keep it under control, often for several years. Treatments will also help manage any symptoms, such as pain.
Some men may not respond well to one treatment, but may respond better to another. And when your first treatment stops working, there are other treatments available to help keep the cancer under control for longer.
Independent Prognostic Factors And Impact Of Gleason Score On Css
The results of univariate and multivariate Cox regression analysis on CSS were listed in Table 2. All the variables including Gleason score, age, race, marital status, AJCC stage, T status, N status, M status, PSA level, and therapeutic methods were associated with CSS significantly in the univariate and multivariate Cox analysis .
Table 2. Univariate and multivariate Cox analysis of CSS.
Except Gleason score, independent prognostic factors on CSS were demonstrated in Figure 3, including age , marital status , AJCC stage , T status , N status , M status , race , PSA levels , and therapeutic methods . Specifically, impact of Gleason score 3+4 and Gleason score 4+3 on CSS was showed in Figure 2B, which also indicated CSS advantage of Gleason score 3+4 over Gleason score 4+3 . Gleason score 3+4 had a better 5-year CSS and 10-year CSS than Gleason score 4+3. In the multivariate analysis, Gleason score 4+3 had a significantly higher cancer-specific mortality risk than Gleason score 3+4 .
Figure 3. Survival curves of CSS for age, P< 0.001 Survival curves of CSS for marital status, P< 0.001 Survival curves of CSS for AJCC stage, P< 0.001 Survival curves of CSS for T status, P< 0.001 Survival curves of CSS for N status, P< 0.001 Survival curves of CSS for M status, P< 0.001 Survival curves of CSS for race, P< 0.001 Survival curves of CSS for PSA levels, P< 0.001 Survival curves of CSS for therapeutic methods, P< 0.001.
Prognostic Nomogram For Css
Compared with the nomogram for OS, the nomogram for CSS integrating all the significant independent factors including AJCC stage based on the training cohort is shown in Figure 6B. The C-index for nomogram of CSS prediction was 0.838 , and 0.852 in the training and validation cohort, respectively. The calibration plots indicated an excellent accuracy in prediction for CSS probability at 5 and 10 year in the training cohort and testing cohort .
Questions To Ask Your Doctor
To help understand the progression of prostate cancer, discuss these questions with your doctors:
- What is my Gleason score?
- Has the cancer spread outside my prostate?
- Whats my prostate cancer stage?
- Are other tests needed to determine my cancer stage?
- What are the treatment options for my stage of cancer?
- Can I avoid treatment right now and go on active surveillance?
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Natural History And Genetic Features Of Low
The chief dilemma in managing clinically localized prostate cancer stems from the heterogeneity of the disease. Prostate cancer arises from genetically altered prostate epithelium and slowly progresses over several decades. Given its features of multifocality and tumor heterogeneity, the course of prostate cancer is difficult to predict. Men may live their entire natural life without having any symptoms from prostate cancer. Zlotta et al confirmed this hypothesis when they prospectively compared tissue obtained during autopsy from prostate glands in both a Caucasian and an Asian population. Prostate cancer was found in a similar proportion of men in both groups. Also, more than 50% of the cancers in the Asian group had a Gleason score of 7 or greater. The natural history of this disease, which is characterized by slow progression, makes it possible for active surveillance to be an effective management strategy.
The key point here is that most Gleason 6 cancers have innocent genetic features and no risk of metastasis. Thus, in the absence of higher-grade cancer, there is little indication for treatment in most patients.
Prostate Cancer Survival Rates Are Favorable Overall
Thinking about survival rates for prostate cancer takes a little mental stretching. Keep in mind that most men are around 70 when diagnosed with prostate cancer. Over, say, five years, many of these men will die from other medical problems unrelated to prostate cancer.
To determine the prostate cancer survival rate, these men are subtracted out of the calculations. Counting only the men who are left provides what’s called the relative survival rate for prostate cancer.
Taking that into consideration, the relative survival rates for most kinds of prostate cancer are actually pretty good. Remember, we’re not counting men with prostate cancer who die of other causes:
- 92% of all prostate cancers are found when they are in the early stage, called local or regional. Almost 100% of men who have local or regional prostate cancer will survive more than five years after diagnosis.
- Fewer men have more advanced prostate cancer at the time of diagnosis. Once prostate cancer has spread beyond the prostate, survival rates fall. For men with distant spread of prostate cancer, about one-third will survive for five years after diagnosis.
Many men with prostate cancer actually will live much longer than five years after diagnosis. What about longer-term survival rates? According to the American Society of Clinical Oncology, for men with local or regional prostate cancer:
- the relative 10-year survival rate is 98%
- the relative 15-year survival rate is 96%
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Gleason Score On Os And Css In : 1 Matched Group By Psm
With regard to the significant impact of TNM stage on oncology results, and higher metastatic rate in the Gleason score 4+3 compared with Gleason score 3+4 previously described, it still remained unclear whether the OS and CSS advantage of Gleason score 3+4 was confounded with the effects of TNM status. Therefore, we divided the study population with AJCC stage, T status, N status, M status respectively, and then evaluated whether Gleason score 3+4 still exerted OS and CSS advantage over Gleason score 4+3 after TNM status stratification. As shown in Figure 4, compared with Gleason score 3+4, Gleason score 4+3 still showed OS and CSS disadvantage in Stage II , Stage III/IV , T1/2 ,T3/4 , N0 , N1 , M0 , and M1 .
Figure 4. Survival curves of OS for Stage II divided by Gleason score, P< 0.001 Survival curves of OS for Stage III/IV divided by Gleason score, P< 0.001 Survival curves of CSS for Stage II divided by Gleason score, P< 0.001 Survival curves of CSS for Stage III/IV divided by Gleason score, P< 0.001 Survival curves of OS for T1/2 divided by Gleason score, P< 0.001 Survival curves of OS for T3/4 divided by Gleason score, P< 0.001 Survival curves of CSS for T1/2 divided by Gleason score, P< 0.001 Survival curves of CSS for T3/4 divided by Gleason score, P< 0.001.
Quality Of Life With Advanced Stage Prostate Cancer
Since Huggins and Hodges won a Nobel Prize in 1966 for their work describing the relationship between testosterone and prostate cancer, androgen deprivation has continued to be an important component in the treatment of advanced prostate cancer. It is associated, however, with significant cost in terms of morbidity as well as economics. Side effects of androgen deprivation therapy include hot flashes, osteoporosis, loss of libido or impotence, and psychological effects such as depression, memory difficulties, or emotional lability. Recently Harle and colleagues reported insulin resistance, hyperglycemia, metabolic syndrome, and metabolic complications being associated with castration and thus being responsible for increased cardiovascular mortality in this population.
Because of the palliative nature of androgen ablation, quality of life is an important component of evaluating competing therapies. Intermittent androgen deprivation is one approach to hormonal therapy that has been developed with the aim of minimizing the negative effects of therapy while maximizing clinical benefits and the patients quality of life. It can be used in any clinical situation where continuous androgen deprivation treatment could be applied.
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Estimation Of Life Expectancy For Newly Diagnosed Men With Prostate Cancer
A critical question for every patient newly diagnosed with prostate cancer is going to be, How long am I going to live? That question may be particularly important if a second and associated question is, How long am I going to live if I just monitor my cancer on active surveillance or watchful waiting?
We know that many men with low-risk and even favorable intermediate-risk prostate cancer can be managed for significant periods of time on active surveillance before treatment actually becomes necessary and that selected men with more aggressive or more advanced disease may be able to delay initiation of treatment because they have a limited life expectancy on account of their age at diagnosis or because they have other significant health issues. However, there has never been a simple tool available that a newly diagnosed patient could use to give him a reasonable estimate of how long he is likely to live and that took account of his prior and existing health issues in addition to his age.
For complex reasons this tool is not perfect. Few such tools ever are. But the authors have been able to show that their model does provide a good and reasonably accurate projection of life expectancy for most reasonably average men being diagnosed with localized prostate cancer. The men for whom it may be less accurate are likely to include those who have hereditary forms of prostate cancer and those who have a long family history of male longevity.
The Risks Of Active Surveillance For Men With Intermediate
- By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Men diagnosed with slow-growing prostate tumors that likely wont be harmful during their lifetimes can often avoid immediate treatment. Instead, they can have their tumor monitored using a strategy called active surveillance. With this approach, doctors perform periodic checks for tumor progression and start treatment only if the cancer begins to metastasize, or spread. Active surveillance has become popular worldwide, but doctors still debate which groups of men can safely use this strategy. Some doctors offer it only to men with the lowest risk of cancer progression. Others say that men with intermediate-risk prostate cancer can also make good candidates.
A new study now shows that intermediate-risk tumors are more likely to metastasize on active surveillance than initially expected. Most men do fine on surveillance, but we have detected a higher risk of metastasis among intermediate-risk patients over the long term, said Dr. Laurence Klotz, director of the active surveillance program at the University of Torontos Sunnybrook Health Sciences Centre, where the study was based.
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Prognostic Grouping Of Prostate Cancer
TNM prognostic grouping for prostate cancer is based on the stage, PSA level and Gleason score. This grouping is more accurate in predicting a prognosis than TNM staging alone. It goes without saying that the lower the scores, the best outlook and chance that your cancer can be successfully treated without the cancer coming back .
In contrast, if the prognosis is darker for men with higher scores, there may still be treatment options to control your cancer, improve your quality of life and prolong your survival.
Doctors also use nomograms to predict a prostate cancer prognosis. Nomograms are predictive tools.
The Importance Of An Accurate Gleason Score For The Treatment Of Prostate Cancer
Prostate cancer is the most common non-skin cancer in men. About 240,000 American men are diagnosed with prostate cancer each year, and in 130,000, the cancer is localized and low-risk. Although most prostate cancers are slow growing and unlikely to spread, most men receive immediate treatment with surgery or radiation. These therapeutic strategies are associated with short- and long-term complications, including impotence and urinary incontinence. Only a small number of men choose observational strategies, which may delay the initiation of curative therapy or avoid it completely.
Although the value of screening with a PSA serum blood test has come under question recently, it is still the only widely available screening test for prostate cancer. While a single PSA value alone may have debatable value, PSA velocity and PSA density can be indicators of change, good or bad. Biopsy of the prostate gland is frequently necessary to distinguish between the causes of an elevated serum PSA.
Dr. Feller is a Board Certified Radiologist at Desert Medical Imaging which has a MRI based prostate cancer program. Please visit their website www.desertmedicalimaging.com for more information or call 760.694.9559.
Watchful Waiting And Active Surveillance
Watchful waiting is an adequate approach in patients who are at low risk of death from prostate cancer because of their limited life expectancy due to severe comorbidities., Watchful waiting resulted in similar overall survival when compared with radical prostatectomy, but disease-specific survival was better in patients who had undergone surgery. For some patients it turns out to be hard to persist on a watchful waiting policy, and many men drop out and seek active treatment within several years, mostly when PSA elevation is noted.
Active surveillance is a novel and fascinating approach to distinguish between patients who are at higher risk and need active therapy and patients who are at low risk for disease progression., This approach avoids the risks of therapy while allowing early detection of those patients who are prone to progress. In these high-risk individuals, delayed active treatment is offered. Periodic monitoring of the PSA serum level, digital rectal exam, and repeated prostate biopsies are performed in patients who are on active surveillance, and active therapy is started when predefined threshold values are reached. This concept makes it possible to offer curative treatment to individuals who are at high risk for disease progression as indicated by active surveillance parameters.
Outlook For Men With Localised Prostate Cancer
Most localised prostate cancer is slow-growing and may not need treatment or shorten a mans life. For many men who have treatment for localised prostate cancer, the treatment will get rid of the cancer. For others, treatment may be less successful and the cancer may come back. If this happens, you might need further treatment.
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Staging Spread And Survival Rates
As with all cancers, doctors use the term stage to describe the characteristics of the primary tumor itself, such as its size and how far prostate cancer has spread when it is found.
Staging systems are complicated. The staging system for most cancers, including prostate cancer, uses three different aspects of tumor growth and spread. It’s called the TNM system, for tumor, nodes, and metastasis:
- T, for tumor describes the size of the main area of prostate cancer.
- N, for nodes, describes whether prostate cancer has spread to any lymph nodes, and how many and in what locations.
- M, for metastasis, means distant spread of prostate cancer, for example, to the bones or liver.
Using the TNM system, each man’s prostate cancer can be described in detail and compared to other men’s prostate cancer. Doctors use this information for studies and to decide on treatments.
As far as survival rates for prostate cancer go, however, the staging system is pretty simple. As we’ve mentioned, in terms of survival rates, men with prostate cancer can be divided into two groups: