Transcript Prostate and Bladder Cancer Intensive Review of Internal

Prostate Cancer:
A Case for Active
Surveillance
Philip Kantoff MD
Dana-Farber Cancer Institute
Professor of Medicine
Harvard Medical School
Incidence of Prostate Cancer:
International Comparisons
Dijkman. Eur Urol. 1996;30:281-294.
Clinical Incidence of Prostate Cancer
Has Changed Dramatically Over Time
Mortality Rates for Cancer in the US
From Jemal, A. et al.
CA Cancer J Clin 2006;56:106-130.
Copyright ©2006 American Cancer Society
Autopsy Detection of Prostate Cancer
in Men of Various Ages
Sakr et al. In Vivo. 8:439-43, 1994
Age
20-30
31-40
41-50
51-60
71-80
Cancer
2%
29%
32%
55%
64%
Some Basic Statistics
• What you find depends on how hard you
look
– Autopsy prostate cancer: ~50% of men over 50
– Clinical (PSA) prostate cancer: ~16% of men >
age 50
– Death from prostate cancer: ~3.0% of men >
age 50
Risk of Clinical Prostate Cancer
• Currently risk of prostate cancer is determined by
whether you do a biopsy, how many biopsies you do
and the frequency of biopsies
• The number of PSA driven biopsies have dramatically
changed in the past 20 years
Conclusion: Epidemiology
• Prostate Cancer is the second leading
cause of cancer death among US men
• The vast majority of men who have and
who are diagnosed with prostate cancer
will not die from their disease
• PSA utilization has resulted in an
increased incidence of prostate cancer
Does Treatment Reduce
Mortality?
Randomized Study: Surgery
Versus Active Surveillance
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695 Scandinavian men, 1989-1999
Median f/u 8.2 years
Mean age: 64.7 years
Mean PSA: 12.8 ng/ml
Gleason: 2-6 (61%), 7 (23%), 8-10 (5%)
Overall Survival
Cancer Specific Survival
RR 0.56, p=0.01
Cancer Specific Survival Based
On Age
Increased Risk Of Metastases
With Watchful Waiting
RR 0.60, p=0.004
Conclusions
• Radical local treatment in a largely nonscreened population with localized cancer
leads to improved survival
• The absolute benefit remains small, but is
more significant in men < 65 yrs old
• At this point in followup, 17 RPs for 1 life
saved
Watchful Waiting
• 767 Active Surveillance patients in
Connecticut
• Mean age: 68 years
• Mean f/u: 15.4 years
• Death certificates, path reviewed
Albertson et al
Prognosis as a Function of Age and
Gleason Score: Localized Disease
Albertsen et al. JAMA 280: 975-80
Conclusions
• A subset of men have aggressive disease
that poses a threat to their survival
• Most men with prostate cancer will not die
from their disease. Gleason score,
determined by biopsy, is the most critical
factor in determining prognosis for patients
with localized disease
• Active Surveillance is a reasonable option
for men with life expectancy of less than 10
years or for some men with low volume
(few biopsy cores positive) Gleason 6 or
less tumors