University of Virginia Health System

Prostate Cancer Treatment Decisions Reviewed

A large study concludes that most older men with early prostate cancer do not shorten their survival odds if they adopt a "wait-and-see" approach to the disease.

"Many elderly men with lower risk of cancer may do well with conservative management," concludes study author Grace Lu-Yau of the Cancer Institute of New Jersey.

"Each patient facing a treatment decision has to ask himself what is the potential survival benefit of various treatments and the potential side effects of various treatments," says Lu-Yau.

She says patients should then compare this potential risk of side effects with the potential risk of cancer complications if the cancer is left untreated - and ask themselves which treatment option is their personal preference.

Localized Cancer May Be Left Untreated

The question of whether to treat or not treat prostate cancer has long absorbed experts.

Although one in six men in the U.S. will be diagnosed as having prostate cancer in their lifetime, many of the malignancies are slow-growing, and there is no reliable way to identify which men will benefit from treatment.

Better knowledge of the natural history of the disease (such as what happens without any treatment) would help guide treatment decisions, explains Lu-Yau.

This study is one of the first to look at the natural history of prostate cancer since PSA (prostate-specific antigen) blood testing became commonplace. PSA tests can detect a prostate cancer six to 13 years earlier than previous methods.

Lu-Yau and her colleagues looked at data on more than 9,000 men with Stage I or II prostate cancer diagnosed between 1992 and 2002 who did not undergo treatment. The mean age of participants was 77 years.

Seventy-two percent of these men died of other causes or didn't have enough cancer progression to warrant surgery or radiation, the researchers found. For the remaining 2,675 men who did receive treatment, the median time between diagnosis and start of therapy was more than 10 years.

Not surprisingly, men with less-aggressive forms of the disease survived longer than those with more aggressive tumors.

"For elderly men with localized prostate cancer, the potential survival benefit for treatment is most likely modest, therefore it is very critical to weigh the risk of having side effects of various treatments with the risk of developing cancer-related complications down the road," says Lu-Yau. "The majority of patients will die of other causes or remain alive without significant major complications."

William Steers, M.D., Chair of the University of Virginia Health System's Department of Urology, says many physicians agree that prostate cancer patients with localized disease tend to be overtreated, "which for cancer in and of itself is not a problem if not for the complications and cost of today's therapies."

Deciding whether to treat prostate cancer or take an "active surveillance" approach, he says, is a complicated decision that combines tumor aggressiveness, symptoms, a patient's family history of cancer, any other medical problems a patient has and a patient's life expectancy. In the near future we have better molecular markers to predict the future behavior of prostate cancer and be better able to advise our patients.

When choosing between treatment and the "wait-and-see" approach, Steers says, patients should consider their:

• Tumor characteristics
• Risk tolerance and anxiety
• Overall health
• Doctor's recommendation
• Ability to live with the potential side effects of a treatment

Radiation after Cancer Recurs May Help

A second study presented at the conference found that giving salvage radiation therapy (SRT) to men whose PSA levels rise after having their prostate removed can reduce their risk of dying from the cancer by more than 60 percent.

SRT is typically given only after a recurrence of prostate cancer, notes study lead author Dr. Bruce Trock of Johns Hopkins University School of Medicine.

Existing studies have either not been large enough or long enough in duration to determine if SRT prolongs survival.

In this retrospective analysis of 635 men who had experienced a recurrence of cancer after having their prostate removed, 62 percent of those who did not receive any salvage therapy were still alive after 10 years, compared with 86 percent of those who received SRT and 82 percent of those who received SRT plus hormone therapy.

Men whose PSA doubling time (the amount of time it took for PSA levels to double from when it first becomes detectable) was six months or less had the greatest benefit.

"If another study was able to replicate our data, it could lead to a clinical trial that would eventually support a way to determine who should get immediate adjuvant radiation and who could wait until the time of recurrence to have SRT," Trock says. "The question is, could a benefit be achieved in some of these men if you waited to see whether they recurred or not?"

To learn more about prostate cancer or other men's health issues, visit www.uvahealth.com.

Always consult your physician for more information.