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Doing
Nothing Until Metastatic Prostate Disease Develops
March 29, 2007
This option has been most fully explored by Drs. Walsh, Partin
and Eisenberger at Johns Hopkins University (JHU). At this JHU,
it has long been the practice not to treat patients who have
a rising PSA as the only evidence of recurrent prostate cancer.
At the heart of this approach is the realization that men do
not die of an increasing PSA, but of cancer metastatic to bone
and other organs. For this reason, they do not treat until metastases
are evident. Because JHU is also one of the leading centers for
radical prostatectomy, they have a large number of patients who
have been followed very carefully for many years. They have recently
reported (Partin, A.W. et al) detailed analysis of this approach.
Of 4,415 patients who underwent radical prostatectomy, 825 had
recurred as demonstrated by an increasing PSA. The average time
to recurrence was 8.4 years. Of the 825, 170 or 20.6% had developed
metastatic disease in the bones or other sites outside the pelvis
and 109 or 13% had died of prostate cancer. Earlier studies suggested
that Gleason grade, the time between surgery and relapse, and
the rate at which the PSA doubled all correlated with the risk
of distant metastases. In this paper, they had larger numbers
of patients followed for longer intervals. With this added information,
researchers found that the PSA doubling time or PSA-DT was by
far the most powerful predictor of the risk of metastates and
of the risk of dying of prostate cancer. Below, is the key table
from that paper.
As you can see, for those patients where the PSA doubling time
was greater than 10 months, 85% were still alive 10 years after
relapse. On the other hand, for those with a PSA doubling time
shorter than 10 months, only 47% were alive at 10 years.
Based on my experience, I think these figures are largely correct
and that men with a PSA doubling time of greater than 10 to 12
months are likely to do quite well for many years without treatment.
On the other hand, JHU investigators present no data to suggest
that this approach makes sense if your PSA doubling time is faster
than 10 months. This approach would seem to be particularly well
suited to men with other health problems who are not likely to
survive more than 10 years. For example, men with poorly controlled
diabetes or hypertension and those with serious cardiovascular
disease, fit this model.
I would also point out that the numbers in the table represent
the percentage of men still alive. To state the obvious, those
who died were not doing well for some time prior to their death.
It is an open question whether earlier interventions might have
brought these men more quality time or whether the treatments
would not have been as onerous as the disease. I think some of
the treatment options cause no side effects, while others cause
serious problems. As you read this newsletter, reflect on the
price you must pay for the benefit offered.
The rest of this article can be read in Volume 9 Issue 9 of Prostate
Forum. Click here to download this issue now. |
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