Prostate Cancer and the Younger Patient

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In recent years, a number of studies purport to show that active surveillance with the potential for delayed treatment (AS-DT) is a feasible option for selected prostate cancer patients, namely those with low-risk tumors.

 

Some of the latest studies, presented at the 2008 annual meeting of the American Urological Association, are described in this issue. In one study, Scott Eggener, MD, and colleagues from the University of Chicago Medical Center, looked at 262 men who chose active surveillance for initial management of low-risk tumors.

 

After a median follow-up of 29 months, 43 patients eventually underwent primary therapy. The one-, two-, and five-year actuarial probabilities of remaining on AS were 95%, 91%, and 75%, respectively.

 

In another study, a team led by William V. Shappley III, MD, of Brigham and Women's Hospital in Boston, identified 2,134 men in the Health Professionals Follow-up Study who were diagnosed with prostate cancer between 1986 and 2002. Of these men, 169 (7.9%) chose deferred treatment for their initial management.

 

After a mean follow-up of seven years, 89 men (53%) remained untreated. The AS-DT group and the men who opted for immediate treatment had similarly low rates of clinical metastases and prostate cancer death.

 

Researchers emphasize that careful patient selection is key. One of the factors commonly considered in deciding on active surveillance is life expectancy. A rule of thumb mentioned in the literature is that this approach should be reserved for patients expected to live less than 10 years. The idea is to spare these patients the complications of treatment, such as urinary incontinence and erectile dysfunction.

 

But what about younger patients, such as those in their 50s? Although right now they make up only a minority of patients, with the widespread use of PSA screening, this is a cohort that is growing. Their life expectancy is greater than 10 years, and conventional wisdom holds that this makes active surveillance more risky.

 

But, as Dr. Eggener points out, data are unavailable to advocate for or against this strategy in younger patients. Given the quality of life implications of prostate cancer treatment, it appears that now is the time to look at risks of progression of prostate cancer in younger patients.

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