Another new study

Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer (NEJM, 2023)

"Abstract

BACKGROUND
Between 1999 and 2009 in the United Kingdom, 82,429 men between 50 and 69 years of age received a prostate-specific antigen (PSA) test. Localized prostate cancer was diagnosed in 2664 men. Of these men, 1643 were enrolled in a trial to evaluate the effectiveness of treatments, with 545 randomly assigned to receive active monitoring, 553 to undergo prostatectomy, and 545 to undergo radiotherapy.

METHODS
At a median follow-up of 15 years (range, 11 to 21), we compared the results in this population with respect to death from prostate cancer (the primary outcome) and death from any cause, metastases, disease progression, and initiation of long-term androgen-deprivation therapy (secondary outcomes).

RESULTS
Follow-up was complete for 1610 patients (98%). A risk-stratification analysis showed that more than one third of the men had intermediate or high-risk disease at diagnosis. Death from prostate cancer occurred in 45 men (2.7%): 17 (3.1%) in the active-monitoring group, 12 (2.2%) in the prostatectomy group, and 16 (2.9%) in the radiotherapy group (P=0.53 for the overall comparison). Death from any cause occurred in 356 men (21.7%), with similar numbers in all three groups. Metastases developed in 51 men (9.4%) in the active-monitoring group, in 26 (4.7%) in the prostatectomy group, and in 27 (5.0%) in the radiotherapy group. Long-term androgen-deprivation therapy was initiated in 69 men (12.7%), 40 (7.2%), and 42 (7.7%), respectively; clinical progression occurred in 141 men (25.9%), 58 (10.5%), and 60 (11.0%), respectively. In the active-monitoring group, 133 men (24.4%) were alive without any prostate cancer treatment at the end of follow-up. No differential effects on cancer-specific mortality were noted in relation to the baseline PSA level, tumor stage or grade, or risk-stratification score. No treatment complications were reported after the 10-year analysis.

CONCLUSIONS
After 15 years of follow-up, prostate cancer–specific mortality was low regardless of the treatment assigned. Thus, the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer. (Funded by the National Institute for Health and Care Research; ProtecT Current Controlled Trials number, ISRCTN20141297. ClinicalTrials.gov number, NCT02044172."

This was featured on national news last evening.

It was touted as a revolutionary "breakthrough" in prostate cancer treatment, and I thought a NEW approach was going to be revealed.

I felt this didn't represent a new approach, as active surveillance isn't new.

Personally, I get far more excited when a brand NEW medication or treatment emerges that represents innovative treatments that will help our battle brothers who need additional weapons in the arsenal.

With that being said, continuing research is imperative ~ and the only true path forward.

Here's to that thought ~ ongoing research!

CYCLONE ~ # Iowa State University

OK, so you've got good chances of making it 15 years past your diagnosis. Then what happens?

Djin

What worried me is that this fellow they interviewed - maybe around 65 - recently diagnosed with prostate cancer ~gave the indication to viewers that he was "off the hook" and didn't need to seek treatments now, at all.

Each case IS different ~ but I don't think anyone diagnosed with cancer should be lulled into the idea that they are "off the hook" ~ in terms of treatment.

The "laissez faire" narrative worried me.

I think vigilance is key. We have lost a lot of battle brothers here, through the years.

We owe it to them to advocate for remaining proactive, doing one's due diligence, getting a second opinion, and researching new treatment options.

You already know I will truly celebrate the day when another NEW weapon - like PLUVICTO (Lutetium-177) in recent times ~ gets added to the arsenal of WEAPONS.

Looking forward ~ stay strong in the battle, compadres!

CYCLONE ~ # Iowa State University

I dunno. My cancer progressed and that was enough for me and I sought out treatment. Suppose I knew it was not going to get better and most likely worse.
Biopsy results are not conclusive since it's hit or miss so maybe a higher grade was missed.
In the end I regret the side effects but am happy I did the treatment.

Glen

This link is a better explanation:
https://www.cnn.com/2023/03/11/health/prostate-cancer-surveillance-survival/index.html

I am a long time advocate for active surveillance, and have always been concerned with how AS was defined in that study. Those men made their choices before 2012, and almost all had only a transrectal (blind) biopsy, with no MRI or genomics testing. Also, the monitoring protocols were far less strict than we have at our AS programs, such as at Hopkins or MSKCC.

So, I believe that the AS outcomes, while good, would be even better with today’s diagnostics and follow-up testing.

The study tells me that AS can be quite risky. 9% in the AS group ended up with metastasis compared to 5% in the treatment groups. Obviously, those in the AS group had less risky cases, so the risk of eventual metastasis should be much less.

Those in the AS group were later treated if deemed necessary. Yet those who chose AS nearly doubled their risk of metastatic prostate cancer compared to those who were promptly treated.
So choosing AS gives you about equal odds of being alive in 15 years with a chance of no treatment side effects IF the cancer doesn't progress. At the same time it at least doubles your risk of having metastatic prostate cancer if it does progress. It would appear that a significant number of those who choose AS miss their opportunity for cure.

AS seems like a pretty poor choice unless your age or health tells says you won't live another 15 years anyway.

Post Edited (Stampede) : 3/13/2023 7:23:27 AM (GMT-8)

As someone who is active and in general good health but diagnosed with PC (Gleason 4 + 3 w/ EPE on one side) at age 60, I hope to actively live much longer than 75, and am glad that I had the RALP when I did. I don't think AS would have been beneficial in my case.

Stampede said...
Obviously, those in the AS group had less risky cases, so the risk of eventual metastasis should be much less.

No, this cohort was randomized going in as to their treatment, AS, surgery, or RT.

Stampede said...

Those in the AS group were later treated if deemed necessary. Yet those who chose AS nearly doubled their risk of metastatic prostate cancer compared to those who were promptly treated.

So choosing AS gives you about equal odds of being alive in 15 years with a chance of no treatment side effects IF the cancer doesn't progress. At the same time it at least doubles your risk of having metastatic prostate cancer if it does progress. It would appear that a significant number of those who choose AS miss their opportunity for cure.

Not really. From the paper...

The higher incidence of metastatic disease in the active-monitoring group at 10 years was anticipated to have an effect on prostate cancer–specific mortality at 15 years, but this was not the case. Among the 40 men in whom metastatic disease had been diagnosed at 10 years, the risk of death from prostate cancer was lower among those in the active-monitoring group (3 of 22 [13.6%]) than in either the prostatectomy group (2 of 8 [25.0%]) or the radiotherapy group (7 of 10 [70.0%]) (Fig. S6).

It makes sense that the AS folks would have a higher metastatic disease rate. The RP and RT cohorts all had treatment straight out, and likely had unknown metastatic disease removed as a result. Then they still had a lot that had their disease progress.

There were a lot of people who were treated with RP and RT who could have deferred their treatment and the resulting side effects for a long time and still had equal outcomes. There are a lot who have never needed treatment.

I wonder how many men who received no treatment during those 15 years had their cancer get worse but hadn't died by the end of the study. One could be stage IV with untreatable Mets but still be alive for the studies data. I'm not being critical of the AS decision, I wish AS could have been an option for me. I just hope men reading the article understand it isn't always safe to delay PC curative treatment.

Jack64 said...
This study makes no sense at all to me. It is almost like getting treatment for PC kills more than doing nothing once a DX for PC has happened. I understand less testing and SEs on AS would be liked over more aggressive treatments.
Jack

Most of the people on AS did eventually seek treatment, so it's more between immediate treatment versus deferred.