Prostate news article, June 2005
| CONSERVATIVE
MANAGEMENT OF CLINICALLY LOCALISED PROSTATE CANCER - 20 YEAR
FOLLOW UP
Albertsen et al Article in JAMA. 2005; 293:2095-2101 Reviewed by: Mr. J Bhardwa MBChB MRCS |
This recent paper follows the progress of 767 men who were diagnosed with prostate cancer 20 years ago. This study only measured the progress of patients who had been merely been observed or given hormonal therapy (anti-testosterone drugs) to halt the progress of the prostate cancer ie none of the patients were intended to be cured. As this study started 20 years ago, data on PSA testing and other modern investigations such as bone scans were not available to gauge how much the cancer had spread, but on information available at the time all the patients were thought to have cancer that had not spread beyond the prostate (clinically localised)
The analysis of these results essentially shows that the most important determinant of outcome in men who lived for 15 - 20 years after the cancer was diagnosed was the Gleason score. Men with low Gleason scores (2-4) did the best and had a much lower chance of dying due to prostate cancer after 20 years. Men with high Gleason score (8, 9, 10) did the worst and therefore these men (with cancer that had not yet spread) should be offered radical treatment, whether it is surgery, radiotherapy etc. Such men also have a high chance of their cancer returning even after radical treatment.
The treatment of men with an intermediate Gleason score (5, 6, 7) was not obvious but the authors concluded that until further evidence becomes available these men should be treated aggressively and offered curative options.
This paper also raises some interesting questions about PSA screening. The argument against screening every man above a certain age (55) is that it will just pick up the slow growing low grade cancers that, even if left alone, pose no harm.
So to summarise:
1. On current evidence and thinking, men with early prostate cancer and a Gleason score greater than 4 should be offered radical therapy provided they are expected to live for the next 15 years
2. Better markers need to be developed to identify which men are going to have a recurrence of their cancer after radical therapy (especially for Gleason score > 4)
3. It is necessary to wait for the results of proper trials currently being conducted in England, Sweden and USA before a decision can be made regarding the routine PSA screening for men over a certain age.