10-year prostate cancer mortality with conservative management better in PSA era

An analysis of decades of results showed that patients diagnosed with localized prostate cancer and treated with conservative management since the beginning of the current PSA era, 1992-2002, had better outcomes than patients diagnosed in the 1970s and 1980s.

Researchers reviewed the cases of 14,516 men aged older than 65 who were diagnosed with stage T1 or T2 disease. Data were collected from the SEER database. Three-quarters of the men had Gleason scores between 5 and 7.

The researchers found 10-year disease-specific mortality was 6% (95% CI, 4%-8%) for men in the contemporary PSA era compared with 15% to 23% for men aged 65 to 74 diagnosed with moderately differentiated disease from 1942-1992. The researchers added that survival also improved among older patients and those with poorly differentiated tumors in the contemporary era.

The results also showed that 10-year prostate cancer–specific survival with conservative management has increased from 83% to 87% in the pre-PSA or early PSA era to roughly 94% now, according to the researchers. They also noted that 94% is better than the 90% rate for men treated with prostatectomy during the pre-PSA or early PSA era.

“In summary, our findings suggest that outcomes following conservative management of contemporary PSA- era patients with localized prostate cancer are substantially more favorable than studies from earlier eras,” the researchers wrote. “Patients with well- or moderately differentiated disease managed conservatively are generally even more likely to die of causes other than prostate cancer.” – by Jason Harris

Lu-Yao GL. JAMA. 2009;302:1202-1209.

Like all nonrandomized, retrospective analyses, there is much more we could wish for with these results, but this analysis does provide strong evidence that since the 'PSA era' began, the risk of prostate cancer death at 10 years in men with localized disease has improved more than 50% in men with tumors less than Gleason grade 8. These data also emphasize the substantial difference between 'low-grade' Gleason tumors, less than 8, and Gleason 8, 9, 10 disease. There are many potential explanations for the improvement in prognosis for men with localized, Gleason less than 8 tumors over time, such as lead-time bias, over-diagnosis and grade migration. Regardless, this study emphasizes the need to develop indicators of dangerous disease that complement our limited markers and should remind physicians and patients that in patients with an expected life expectancy greater than 10 years and a localized prostate cancer with a Gleason score less than 8, active surveillance/expectant management is a very viable option.

– Donald L. Trump, MD

HemOnc Today Editorial Board member