UROLOGICAL ONCOLOGY

Local progression among men with conservatively treated localized prostate cancer: results from the Transatlantic Prostate Group
Eastham JA, Kattan MW, Fearn P, Fisher G, Berney DM, Oliver T, et al.
Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
Eur Urol. 2008; 53: 347-54

• Objectives: Men with clinically detected localized prostate cancer treated without curative intent are at risk of complications from local tumor growth. We investigated rates of local progression and need for local therapy among such men.
• Methods: Men diagnosed with prostate cancer during 1990-1996 were identified from cancer registries throughout the United Kingdom. Inclusion criteria were age < or =76 yr at diagnosis, PSA level < or =100 ng/ml, and, within 6 mo after diagnosis, no radiation therapy, radical prostatectomy, evidence of metastatic disease, or death. Local progression was defined as increase in clinical stage from T1/2 to T3/T4 disease, T3 to T4 disease, and/or need for transurethral resection of the prostate (TURP) to relieve symptoms >6 mo after cancer diagnosis.
• Results: The study included 2333 men with median follow-up of 85 mo (range: 6-174). Diagnosis was by TURP in 1255 men (54%), needle biopsy in 1039 (45%), and unspecified in 39 (2%). Only 29% were treated with hormonal therapy within 6 mo of diagnosis. Local progression occurred in 335 men, including 212 undergoing TURP. Factors most predictive of local progression on multivariable analysis were PSA at diagnosis and Gleason score of the diagnostic tissue (detrimental), and early hormonal therapy (protective). We present a nomogram that predicts the likelihood of local progression within 120 mo after diagnosis.
• Conclusions: Men with clinically detected localized prostate cancer managed without curative intent have an approximately 15% risk for local progression within 10 yr of diagnosis. Among those with progression, the need for treatment is common, even among men diagnosed by TURP. When counseling men who are candidates for management without curative intent, the likelihood of symptoms from local progression must be considered.
  
  
• Editorial Comment
  The course of conservatively treated patients with prostate cancer is largely unknown. These patients are rarely found in clinical trials and therefore, knowledge is sparse. This multi-institutional group of authors followed a large cohort of 2333 patients for a median of 85 months and determined the rate of progression. The results are hampered by the fact that 54% of cases were detected by initial transurethral resection of the prostate, that is, by symptoms of prostate cancer. Still, the 10-year disease-specific mortality rate was 24%. Roughly, 15% of patients had progression, most within 5 years after diagnosis. Most important risk factors were high initial PSA, T3 disease and Gleason grade 4. Interestingly, early hormonal treatment was associated with significantly less progression. As the authors state correctly, these findings suggest that there is a subgroup of men with prostate cancer in whom conservative management might be the preferred option. Men with worrisome clinical features in contrast might benefit from treatment that is more active.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de