The role of watchful waiting in the management of localized prostate cancer

Too much medicine? Scientific and ethical issues from a comparison between two conflicting paradigms

BACKGROUND

The role of medicine in society appears to be focused on two views, which may be summarized as follows: "Doing more means doing better" (paradigm A) and "Doing more does not mean doing better" (paradigm B).

MAIN BODY

I compared paradigms A and B both in terms of a single clinical condition and in the general context of a medical system. For a single clinical condition, I analyzed breast cancer screening. There are at least seven interconnected issues that influence the conflict between paradigms A and B in the debate on breast cancer screening: disconnection between research and practice; scarcity of information given to women; how "political correctness" can influence the choice of a health policy; professional interests; doubts about effectiveness; incommensurability between harms and benefits; and the difficulty in making dichotomous decisions with discrete variables. As a general approach to medicine, the main representative of paradigm A is systems medicine. As representatives of paradigm B, I identified the following approaches or movements: choosing wisely; watchful waiting; the Too Much Medicine campaign; slow medicine; complaints against overdiagnosis; and quaternary prevention. I showed that both as a single condition and as a general approach to medicine, the comparison was entirely reducible to a harm-benefit analysis; moreover, in both cases, the two paradigms are in many respects incommensurable. This transfers the debate to the ethical level; consequently, scientists and the public have equal rights and competence to debate on this subject. Moreover, systems medicine has many ethical problems that could limit its spread.

CONCLUSION

I made some hypotheses about scenarios for the future of medicine. I particularly focused on whether systems medicine would become increasingly accessible and widespread in the population or whether it would be downsized because its promises have not been maintained or ethical problems will become unsustainable.

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.

Prostate cancer screening decision making under controversy: implications for health promotion practice

Prostate cancer is a major health problem for U.S. men and is characterized by paradoxes and controversies. Despite the wide availability of the prostate-specific antigen (PSA) test, prostate cancer screening remains a controversial practice mainly because the direct impact of screening on mortality is not yet proven. As the relative value of screening, early detection, and treatment strategies continue to be debated, glaring racial-ethnic disparities persist with African American men experiencing excess morbidity and mortality and demonstrating the lowest screening rates among racial-ethnic groups. Given the prevailing controversy, uncertainty, and known disparities, how can health education messages be framed to assist men and their family members? This article highlights the ethnic disparities, paradoxes, and controversies of prostate cancer and identifies critical challenges and opportunities for health educators and clinical practitioners. Implications for health promotion communications and informed decision making in this era of uncertainty are discussed.

Correlation of Gleason scores between needle-core biopsy and radical prostatectomy specimens in patients with prostate cancer

BACKGROUND

The histologic grade of a prostate needle-core biopsy specimen can determine whether a patient with prostate cancer is a candidate for radical prostatectomy or other treatment. Incorrect histologic grading can result in inappropriate treatment and possible liability. Thus, we conducted this study to determine the histologic-grading accuracy of prostate cancer needle-core biopsy specimens.

METHODS

Fifty-two patients with localized prostate cancer treated with radical prostatectomy were included in the study. The overall correlation between Gleason scores for needle-biopsy and prostatectomy specimens was evaluated by analyzing the following parameters: biopsy-core number; accurate biopsy-core length; prostate volume; and preoperative, serum prostate-specific antigen (PSA) level. A "downgrade" was defined as the Gleason score for the prostatectomy specimen being greater than that for the biopsy specimen, whereas an "upgrade" was defined as the converse.

RESULTS

No difference in Gleason scores was noted for 31% of specimens, whereas a downgrade was noted for 40%, and an upgrade for 29%. The accuracy of Gleason scores for biopsy specimens taken by the sextant systemic-biopsy method increased when specimens were >15 mm in length. No correlation was noted between difference in Gleason scores and biopsy-core number, prostate volume, and preoperative serum PSA level.

CONCLUSION

The accuracy of Gleason scores determined by needle biopsy in patients with prostate cancer seems to be unreliable. Therefore, further evaluation of patients is necessary. No correlations were noted between biopsy-measured errors in Gleason score and biopsy number, prostate volume, or preoperative serum PSA level.

Preservation of prostate during radical cystectomy: Evaluation of prevalence of prostate cancer associated with bladder cancer

OBJECTIVES

To estimate the frequency and characteristics of prostatic lesions discovered incidentally in radical cystoprostatectomy specimens and to determine whether any factors would allow for the detection of prostate cancer preoperatively.

METHODS

A total of 100 radical cystoprostatectomy specimens with orthotopic bladder reconstruction were performed for malignant bladder disease between 1990 and 2000. The mean patient age at surgery was 62 +/- 8 years (range 32 to 75). Digital rectal examination and prostate-specific antigen (PSA) assay were done routinely before surgery. During the 10-year study period, the same pathologist examined the prostatic tissues from radical cystoprostatectomy specimens using McNeal's technique on fine slices every 2.5 mm.

RESULTS

The overall incidence of prostate cancer discovered incidentally in radical cystoprostatectomy specimens was 51%, of which 29% were microcancers (volume less than 0.5 cm3) and 22% were significantly larger (volume 0.5 cm3 or more). The mean Gleason score was 6. Of the tumors, 24% could be considered "clinically nonsignificant" (less than 0.5 cm3 and Gleason score less than 7). The mean preoperative PSA level was 4.13 +/- 1.36 ng/mL. Of 66 patients with a PSA level of less than 4 ng/mL (mean PSA 1.5 +/- 0.8) and a normal digital rectal examination before surgery, 50% had prostate cancer, of which 69% were microcancers.

CONCLUSIONS

The prevalence of prostate cancer (51%) in our series is among the highest in published reports. Furthermore, our results stress that currently no factors are available to enable the detection of "clinically significant" prostate cancer preoperatively.

Active surveillance with selective delayed intervention is the way to manage 'good-risk' prostate cancer

This review summarizes the case for active surveillance of 'good-risk' prostate cancer, with selective delayed intervention for rapid biochemical progression, assessed by rising prostate-specific antigen (PSA) levels or grade progression. The results of a large phase II trial using this approach are also reviewed. A prospective phase II study of active surveillance with selective delayed intervention was initiated in 1995. Patients were managed initially with surveillance; those who had a PSA doubling time (PSADT) of < or = 2 years, or grade progression on repeat biopsy, were offered radical intervention. The remaining patients were closely monitored. The cohort now consists of 299 patients with good-risk--or, in men over 70 years of age, intermediate-risk--prostate cancer. The median PSADT was 7 years, 42% had a PSADT > 10 years. The majority of patients remain on surveillance. At 8 years, overall actuarial survival was 85%, and disease-specific survival was 99%. To date, this study has shown that most men with 'good-risk' prostate cancer will die of unrelated causes. The approach of active surveillance with selective delayed intervention based on PSADT represents a practical compromise between radical therapy for all patients, which results in overtreatment for patients with indolent disease, and watchful waiting with palliative therapy only, which results in undertreatment for those with aggressive disease. The results at 8 years were favorable. Longer follow-up will be required if the study is to confirm the safety of this approach in men with a long life expectancy (> 15 years).

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.

Long-term survival following radical prostatectomy in Japanese men with clinically localized prostate cancer: A single institutional study

BACKGROUND

We evaluated the outcome of radical prostatectomy to provide information about long-term survival following this procedure.

METHODS

One hundred and twenty-three otherwise healthy Japanese patients with clinically localized tumors underwent radical prostatectomy. Treatment outcomes were measured in terms of clinical progression-free survival, prostate cancer-specific survival and overall survival. Overall survival was compared with expected survival of age-matched Japanese men.

RESULTS

For these 123 patients, clinical progression-free survival and prostate cancer-specific survival at 10 years were 72.5% and 86.4%, respectively. Results of Cox multivariate analysis showed that only pathological stage (P = 0.047) and tumor grade (P = 0.009) were independent predictors of clinical progression. Only tumor grade was a statistically significant independent predictor (P = 0.048) in terms of prostate cancer death. Both the 10 and 15-year overall survival rates for these 123 patients were 58.6%, whereas the expected survival of age-matched Japanese men was 65.0% at the 10-year follow up, and 43.8% at the 15-year follow up.

CONCLUSIONS

The long-term overall survival in this surgically treated group is comparable to the expected survival rate of age-matched Japanese men. These results might be useful in counselling patients with clinically localized prostate cancer.

[Prostate cancer. Treatment]

The discovery and the utilisation of the prostate specific antigen (PSA) that allows early diagnosis of prostate cancer, have considerably improved the management of this disease. Before the PSA era, prostate cancer was just a disease of the old man, generally detected at an advanced stage and incurable, with a fatal outcome delayed by the androgenic deprivation. Since early 1990's, prostate cancer has become primarily a disease of the man of 60 years, detectable earlier, and curable provided no extraprostatic dissemination has occurred. Early treatment of prostate cancer has benefited from important advances in surgical and radio-therapeutic techniques (conformational irradiation, brachytherapy), with, as principal goal, the combination of a better survival and the reduction of the potential adverse effects that alter quality of life. A better definition of the characteristics of the tumours in terms of progression regarding various parameters (clinical stage, PSA, tumoral differentiation) have resulted, despite the heterogeneity of the disease, in the determination of subgroups of tumours with different prognosis, which leads to an improved therapeutic strategy. The assessment of men's life expectancy (< or > 10 years) is the second primary parameter on which is based the indication for curative or non curative therapy in case of localized tumour. Roughly, before the age of 75, a curative therapy is indicated whereas after this age a surveillance is reasonable as first-line treatment, followed by hormone therapy in case of onset of symptoms indicating some progression of the disease (urinary symptoms, bone lesion). At a Later stage, in case of a metastatic or locally advanced cancer, hormone therapy by androgenic deprivation is highly indicated. The hormone sensitivity characterizes prostate cancer; it has been discovered more than 50 years ago by Charles Huggins (Nobel prize-winner). This hormone therapy is a palliative treatment since its efficacy is transient (ineluctable occurrence of hormone resistance in a variable time delay), but it constitutes an essential therapeutic means with a well-established efficacy. Hormone therapy has progressively improved, with the renunciation of oestrogen therapy and surgical castration which has been replaced by luteinizing hormone-releasing hormone (LH-RH) analogues, and/ or anti-androgens. Numerous works have resulted in a better rationalization of the prescription (date of treatment initiation, interest of combined androgenic deprivation, ...) but uncertainties remain, such as the therapeutic interest of intermittent treatment, or of earlier hormone therapy combined with the treatment of the primitive tumour (adjuvant hormone therapy). Finally, at the time of the hormonal escape of which the molecular mechanisms remain unclear, no therapy has proven any efficacy in survival lengthening, and the treatment remains palliative and symptomatic. Although improved knowledge of prostate cancer aetiology is expected for a real disease prevention, early diagnosis at a curable stage of the disease (by PSA assessment) remains the only means for mortality reduction.

Active Surveillance with Selective Delayed Intervention: A Biologically Nuanced Approach to Favorable-Risk Prostate Cancer

Prostate cancer is an indolent, slow-growing disease in many patients and may not pose a threat during a patient's lifetime. 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. To date, molecular markers have failed to provide sufficiently reliable predictive information to influence decision-making. The approach to favorable-risk prostate cancer described in this article uses estimation of prostate-specific antigen doubling time (PSA DT) to stratify patients according to the risk of progression. Patients who select this approach initially undergo management with active surveillance; those who have a PSA DT <or=3 years (based on a minimum of 3 determinations over a period of 6 months) are offered radical intervention. The remainder are closely monitored. In a series of 231 patients in a study by our group, the median doubling time was 7.0 years; 42% had a PSA DT > 10 years and 20% had a PSA DT > 100 years. The majority of patients in this study continue to undergo surveillance. The approach of active surveillance with selective delayed intervention based on PSA DT represents a practical compromise between radical therapy for all (which results in overtreatment of patients with indolent disease) and watchful waiting with palliative therapy only (which results in undertreatment of patients with aggressive disease).

Population Screening for Prostate Cancer and Emerging Concepts for Young Men

Prostate cancer is the most common malignancy in American men, accounting for > 29% of all diagnosed cancers and approximately 13% of all cancer deaths. Nearly 1 of every 6 men will be diagnosed with the disease at some time in their lives. In 2003 alone, an estimated 221000 men in the United States will be diagnosed with prostate cancer and > 28000 will die of the disease. An elevated level of prostate-specific antigen (PSA) is correlated with the presence of prostate cancer, and since 1989 we have been living in the "PSA era," in which the PSA screening test is widely used in clinical practice. This article summarizes what has been learned about the use of PSA screening, including the intricacies of free PSA, PSA doubling time, and various factors that may affect PSA and confound screening in young men. Although population-based screening for prostate cancer has yet to be definitively proven to affect disease-specific mortality, PSA testing is detecting cancers in younger men and at earlier stages of disease progression and, partly as a result, 5-year cancer-specific survival is increasing. Even though this lead-time effect may not translate into long-term improvement, these changes are very promising and are a necessary prerequisite to effective screening. For patients at high risk with a family history of the disease and for black men, a strategy consisting of an annual PSA blood test and digital rectal examination for men >or=40 years of age appears to be prudent. Use of age- and race-specific reference ranges for PSA based on sensitivity, or maximal cancer detection, is the most appropriate approach in this high-risk group. Specifically among black men 40-49 years of age, those with a PSA value > 2.0 ng/mL should consider further evaluation. Many men at low/average risk aged 40-49 years also request testing and it is reasonable to offer testing and risk assessment to these young men. The exact screening threshold for total PSA in these men is unknown, but 95% of these men will have a PSA < 2.5 ng/mL. Prostate-specific antigen velocity, percentage of free PSA, and perhaps complexed PSA may be used to help determine risk, but further study of young men is needed. In the future, a risk-stratified approach using molecular biomarkers and/or proteomics in young men is anticipated.

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.

Gleason score predicts androgen independent progression after androgen deprivation therapy

OBJECTIVE

The Gleason system is the most widely utilized histologic grading system for prostate cancer and a powerful predictor of cancer behavior. In this study, we evaluated the prognostic value of the Gleason grading system in predicting progression to androgen independent prostate cancer (AIPC).

METHODS

Records from 150 patients with advanced or metastatic prostate cancer treated with androgen deprivation therapy (ADT) were retrospectively reviewed. Androgen independent progression was defined as two consecutive elevations of serum prostate specific antigen (PSA) above the nadir value. Kaplan-Meier and the Cox proportional hazards methods were used to assess potential predictors of progression to AIPC.

RESULTS

Patients with low and moderate Gleason scores experienced significantly longer remissions compared to those with Gleason score of 8-10 (p=0.0006, Log-Rank test). The cumulative hazard of progressing to AIPC increased by almost 70% for each unit increase in total Gleason score.

CONCLUSION

In this patient cohort the Gleason score was the only independent predictor of progression to AIPC.

The treatment of prostate cancer: an overview of current options

PURPOSE

The purpose of this report is to discuss the current treatment options available to the patient with prostate cancer in all stages of the disease.

OVERVIEW

With the exception of skin cancer, prostate cancer is the most common cancer in men in the United States. Most patients in the current era will present with organ-confined disease, amenable to curative treatment. Treatment for organ-confined disease includes watchful waiting, radical prostatectomy, radiation therapy, and cryosurgery in selective cases. Hormone therapy is the cornerstone of treatment of patients with advanced prostate cancer. There is no curative treatment for hormone-refractory prostate cancer.

CLINICAL IMPLICATIONS

The availability of several therapeutic options for localized prostate cancer warrants careful consideration when planning treatment with curative intent. Patients need to be active participants in decision making, and they must be aware of the benefits and possible complications of the different types of treatment. Patients with advanced prostate cancer need to be aware that hormone treatment will provide temporization and palliation in the majority of cases. Hormone-resistant prostate cancer is refractory to most forms of conventional and experimental therapy.

Molecular prediction of progression in patients with conservatively managed prostate cancer

OBJECTIVES

To report our results with the use of reverse transcriptase-polymerase chain reaction (RT-PCR) as a potential predictor of prostate cancer (CaP) progression in patients managed with watchful waiting. There has been much recent debate about the safety of treating older patients with localized CaP with watchful waiting. The RT-PCR is an assay that can detect small numbers of prostate cells in circulating blood.

METHODS

Blood samples were taken from male and female control patients and from patients with advanced, hormone-treated and untreated localized (watchful-waiting) CaP. Sensitive nested RT-PCR assays were carried out on these samples using primers for both prostate-specific antigen (PSA) and prostate-specific membrane antigen mRNA.

RESULTS

Fifty-one blood samples were taken from patients managed with watchful waiting. Fourteen of these had positive RT-PCR results. These patients had a significantly higher PSA velocity than did the patients with negative RT-PCR results. Circulating prostate cells were detected in 18 of 24 patients with advanced CaP, 2 of 34 patients with stable, hormone-treated CaP, and in none of the negative controls. The assay was able to detect 20 LNCaP cells reliably when added to a 5-mL volunteer blood sample.

CONCLUSIONS

A significant minority (27%) of patients with untreated localized CaP had detectable circulating prostate cells, and these patients tended to have a progressively rising serum PSA level. Despite low-grade disease and sometimes low serum PSA values, these patients may be at risk of early metastatic progression. RT-PCR, in conjunction with existing prognostic tests, may be of use in predicting which "watchful-waiting" patients are at risk of early progression.

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.

Radiation therapy in non-surgically-treated nonmetastatic prostate cancer: geographic and demographic variation

OBJECTIVES

To examine the geographic variation in the use of radiation to treat nonmetastatic prostate cancer and to identify factors that explain the variation in the United States.

METHODS

This study was based on data from the nine geographic regions of the Surveillance, Epidemiology, and End Results Program for 1983 through 1996. Patients with localized or regional prostate cancer who did not undergo surgical treatment were included in the analysis. Logistic regression analysis was used to investigate the influence of geographic and demographic factors on the use of radiation. The squared multiple correlation coefficient R(2) was used to measure the proportion of variation in the selection of radiation explained by each factor of interest.

RESULTS

Compared with San Francisco, the adjusted odds ratios for 6 of the 8 geographic areas had highly significant P values, suggesting the use of radiation therapy varies from region to region. However, geographic location only explained less than 3% of the total variation in the use of radiation. The geographic location explained a much higher proportion of variation in the youngest (younger than 55 years) and the oldest (80 years old or older) groups. Overall, age was the most important factor that influenced the use of radiation.

CONCLUSIONS

The finding that geographic location explains a significant proportion of the variation in the use of radiation in the youngest and oldest age groups demonstrates the outcome of longstanding controversies in the nonsurgical treatment of prostate cancer. Documenting the impact of the interaction of age and geographic location on the treatment approaches provides for better understanding of the impact of patients and physicians making clinical decisions in the management of nonmetastatic prostate cancer.

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.

Cryosurgery for prostate cancer: new technology and indications

Patients diagnosed with prostate cancer who elect to pursue active treatment of their disease must choose among the many available treatment alternatives. Several treatment options now exist for similar-stage disease (clinical T1-3N0M0), including radical prostatectomy, external beam radiation, prostate brachytherapy (PB), and cryosurgical ablation of the prostate (CSAP). This article reviews the current role of CSAP in the treatment of clinically localized prostate cancer. CSAP has a role in the primary treatment of men with high-risk, clinically localized prostate cancer (defined as PSA >10, Gleason score >or=7, or clinical stage >or= cT2B). CSAP (occasionally followed by external beam radiotherapy) appears to offer improved rates of cancer control over other types of single or combination therapies for this high-risk prostate cancer, and it is associated with an acceptable side-effect profile. CSAP should also be the treatment of choice for men with recurrent local disease who have undergone external beam radiotherapy or PB.

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.

Common urologic problems in the elderly. Prostate cancer, outlet obstruction, and incontinence require special management

Urologic problems in elderly patients often require special management that considers life expectancy, general health, and the clinical significance of the disorder. For men with prostate carcinoma or outlet obstruction, new therapies have proliferated in the last 10 years. For elderly women with incontinence, an orderly evaluation process usually results in directed and effective treatment. Finally, long-term use of Foley catheters requires careful attention to detail so that serious problems can be avoided.

An analysis of watchful waiting for clinically localized prostate cancer

PURPOSE

We reviewed recent series of watchful waiting for prostate cancer to place this management strategy in appropriate perspective

MATERIALS AND METHODS

We reviewed the literature and analyzed the 9 articles on watchful waiting published in leading medical journals in the last decade.

RESULTS

Watchful waiting is probably the best treatment option for men with well and perhaps moderately differentiated, low volume prostate cancer who have a life expectancy of less than 10 years. However, the conclusions derived from watchful waiting studies of older men cannot and should not be applied to younger, healthier men or to those with more advanced or aggressive disease. If treated ineffectively, many of these men will die of prostate cancer.

CONCLUSIONS

Most men with prostate cancer who have a life expectancy greater than 10 to 15 years should be treated with curative intent.