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Deferred treatment safe for low-grade prostate cancer

NEW YORK, NY. It is not clear whether men diagnosed with low-grade, localized prostate cancer need immediate, aggressive treatment such as radical prostatectomy (removal of the prostate gland) or radiation therapy. A group of American and Australian researchers now report that deferring treatment until clear progression of the cancer is evident may be a safe, acceptable alternative. Their study involved 88 men who had been diagnosed with localized prostate cancer by needle biopsy or during an intervention (transurethral resection) to deal with an enlarged prostate. The men were between the ages of 44 and 79 years (average age of 65) and had Gleason scores (a measure of the aggressiveness of the tumor) of 2-7 with a median of 5. The average PSA level was 5.9 with a range of 0.09 to 30.2 ng/mL. The men, in consultation with their physician, had all decided to defer radical treatment until there was clear evidence that their cancer was progressing. They had a digital rectal examination (DRE) and PSA measurement every 3 months for the first year and every 6 months thereafter. A repeat biopsy was recommended 6 months after initial diagnosis or if the DRE or PSA tests showed abnormalities. In 61% of the repeat biopsies, no cancer was found. The patients with no cancer on repeat biopsy were highly unlikely to show progression of their cancer. (Editor's note: Could this indicate that their original diagnostic biopsy had produced a false positive result, ie. they did not have cancer in the first place?)

During a median follow-up of almost 4 years (44 months) 22 patients showed progression. The overall probability of experiencing no progression was 67% 5 years after initial diagnosis and 55% after 10 years. In other words, more than half the patients showed no progression 10 years after initial diagnosis. A total of 31 patients were treated during follow-up – 17 because they showed clear progression of the cancer, 7 because of anxiety and their physician's concern that the cancer might be progressing, and another 7 underwent radical treatment because they were unable to live with the fear of cancer. The treatment consisted of radical prostatectomy in 17 cases, radiation therapy in 13 cases, and hormone therapy in 1 case. No recurrence had occurred in the patients treated with radical prostatectomy after an average 15- month follow-up. One recurrence was observed in the 13 radiation therapy patients after an average 20- month follow-up. The researchers conclude that deferring radical therapy may be a safe, acceptable alternative in men at low risk and that the results of a follow-up biopsy is the most significant prognostic factor for progression.
Patel, MI, et al. An analysis of men with clinically localized prostate cancer who deferred definitive therapy. Journal of Urology, Vol. 171, April 2004, pp. 1520-24

Editor's comment: This study clearly shows that not rushing into aggressive treatment is a viable option for men diagnosed with low-grade, localized prostate cancer. The most reliable indicator of the eventual need for treatment would seem to be a positive repeat biopsy result 6 months to a year after the initial biopsy.

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