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Conservative management of prostate cancer in the prostate specific antigen era: the incidence and time course of subsequent therapy.
J Urol 2001; 166(5):1702-6JU

Abstract

PURPOSE

The long natural history of early stage prostate cancer is well recognized and a conservative approach to the treatment of elderly men is often encouraged. We assessed the ability of patients and physicians to adhere to a policy of watchful waiting in the prostate specific antigen (PSA) era.

MATERIALS AND METHODS

We retrospectively reviewed the records of all 199 men with stages T1-2 prostate cancer and PSA less than 20 ng./ml. who in our practice elected watchful waiting. Median followup in the population overall was 3.4 years. We performed Kaplan-Meier actuarial analysis of overall and disease specific survival, and most pertinent survival free from therapy. A questionnaire was administered to record the attitude of patients who ultimately proceeded to treatment to determine how therapy was triggered.

RESULTS

Median patient age was 71 years and median PSA was 6.6 ng./ml. The tumor was impalpable in 52% of patients, Gleason sum was 6 or less in 80% and 11% used some form of herbal remedy or nutritional supplementation. Of the 37 men who died during observation, including 35 of co-morbid illness, only 6 underwent treatment. Overall survival at 5 and 7 years was 77% and 63% but disease specific survival was 98% and 98%, respectively. A total of 64 patients underwent treatment and actuarial freedom from treatment was 56% at 5 years, including 51% and 73% in those younger and older than 75 years at diagnosis. The likelihood of being alive and free from treatment was 43% at 5 years and 26% at 7. Of the 63 men treated 48 (76%) underwent radical therapy (brachytherapy in 17, external beam radiotherapy in 29 and prostatectomy in 2), while only 24% received androgen deprivation. The median PSA increase from diagnosis to treatment in treated patients was 2.9 ng./ml., and it was 0.9 ng./ml. from diagnosis to the last followup in those not treated. Of the treated patients 81% believed that the physician had initiated therapy due to a PSA increase or a nodule. However, physicians recorded having advocated treatment in only 24% of cases.

CONCLUSIONS

When patients do not die of co-morbid illness, they are likely to proceed to therapy well within the first decade after diagnosis (57% by 5 years and 74% by 7). Therapy was usually definitive (radical) and triggered by slight, inevitable PSA increases. The patient perception was that the physicians initiated therapy in response to increasing PSA. However, the physicians more often perceived that treatment was initiated by patients. Therefore, watchful waiting in the PSA era often represents radical therapy delayed by a few years.

Authors+Show Affiliations

Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

11586206

Citation

Zietman, A L., et al. "Conservative Management of Prostate Cancer in the Prostate Specific Antigen Era: the Incidence and Time Course of Subsequent Therapy." The Journal of Urology, vol. 166, no. 5, 2001, pp. 1702-6.
Zietman AL, Thakral H, Wilson L, et al. Conservative management of prostate cancer in the prostate specific antigen era: the incidence and time course of subsequent therapy. J Urol. 2001;166(5):1702-6.
Zietman, A. L., Thakral, H., Wilson, L., & Schellhammer, P. (2001). Conservative management of prostate cancer in the prostate specific antigen era: the incidence and time course of subsequent therapy. The Journal of Urology, 166(5), pp. 1702-6.
Zietman AL, et al. Conservative Management of Prostate Cancer in the Prostate Specific Antigen Era: the Incidence and Time Course of Subsequent Therapy. J Urol. 2001;166(5):1702-6. PubMed PMID: 11586206.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Conservative management of prostate cancer in the prostate specific antigen era: the incidence and time course of subsequent therapy. AU - Zietman,A L, AU - Thakral,H, AU - Wilson,L, AU - Schellhammer,P, PY - 2001/10/5/pubmed PY - 2001/11/3/medline PY - 2001/10/5/entrez SP - 1702 EP - 6 JF - The Journal of urology JO - J. Urol. VL - 166 IS - 5 N2 - PURPOSE: The long natural history of early stage prostate cancer is well recognized and a conservative approach to the treatment of elderly men is often encouraged. We assessed the ability of patients and physicians to adhere to a policy of watchful waiting in the prostate specific antigen (PSA) era. MATERIALS AND METHODS: We retrospectively reviewed the records of all 199 men with stages T1-2 prostate cancer and PSA less than 20 ng./ml. who in our practice elected watchful waiting. Median followup in the population overall was 3.4 years. We performed Kaplan-Meier actuarial analysis of overall and disease specific survival, and most pertinent survival free from therapy. A questionnaire was administered to record the attitude of patients who ultimately proceeded to treatment to determine how therapy was triggered. RESULTS: Median patient age was 71 years and median PSA was 6.6 ng./ml. The tumor was impalpable in 52% of patients, Gleason sum was 6 or less in 80% and 11% used some form of herbal remedy or nutritional supplementation. Of the 37 men who died during observation, including 35 of co-morbid illness, only 6 underwent treatment. Overall survival at 5 and 7 years was 77% and 63% but disease specific survival was 98% and 98%, respectively. A total of 64 patients underwent treatment and actuarial freedom from treatment was 56% at 5 years, including 51% and 73% in those younger and older than 75 years at diagnosis. The likelihood of being alive and free from treatment was 43% at 5 years and 26% at 7. Of the 63 men treated 48 (76%) underwent radical therapy (brachytherapy in 17, external beam radiotherapy in 29 and prostatectomy in 2), while only 24% received androgen deprivation. The median PSA increase from diagnosis to treatment in treated patients was 2.9 ng./ml., and it was 0.9 ng./ml. from diagnosis to the last followup in those not treated. Of the treated patients 81% believed that the physician had initiated therapy due to a PSA increase or a nodule. However, physicians recorded having advocated treatment in only 24% of cases. CONCLUSIONS: When patients do not die of co-morbid illness, they are likely to proceed to therapy well within the first decade after diagnosis (57% by 5 years and 74% by 7). Therapy was usually definitive (radical) and triggered by slight, inevitable PSA increases. The patient perception was that the physicians initiated therapy in response to increasing PSA. However, the physicians more often perceived that treatment was initiated by patients. Therefore, watchful waiting in the PSA era often represents radical therapy delayed by a few years. SN - 0022-5347 UR - https://www.unboundmedicine.com/medline/citation/11586206/Conservative_management_of_prostate_cancer_in_the_prostate_specific_antigen_era:_the_incidence_and_time_course_of_subsequent_therapy_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0022-5347(05)65657-1 DB - PRIME DP - Unbound Medicine ER -