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Treatment of PSA Detected Early Prostate Cancer

Since its introduction in 1991, PSA testing has dramatically changed the landscape of prostate cancer, creating significant rise in cancer incidence and shifting the stage of disease at the time of diagnosis to a much earlier and potentially more curable stage. In the United States alone, an estimated 180,890 cases will be diagnosed in 2016.

Prostate cancer often progresses slowly, and many men die of competing causes. Many men do not benefit from intervention because the disease is either indolent or disseminated at diagnosis. Despite the fact that active surveillance is an option, more than 90% of men in the United States choose to undergo aggressive treatment, even if they have low grade cancer. Treatment for prostate cancer may be associated with bleeding, infection, erectile dysfunction and urinary and fecal incontinence.

This past week, the results of the Prostate Testing for Cancer and Treatment (ProtecT) trial were reported. This trial compared the effectiveness of active surveillance, surgery, and radiotherapy with androgen deprivation in reducing prostate cancer mortality, all cause mortality and the incidence of metastases and disease progression at a median of 10 years of follow-up. Prostate cancer specific survival was at least 98.8% in all groups, and there was no significant difference among the three randomized groups. Deaths from any cause were evenly distributed across the three treatment groups. The incidence of disease progression was higher in the active-monitoring group than in the surgery and radiotherapy groups; 112 men had progression in the active-monitoring group compared to 46 in the surgery group and 46 in the radiotherapy group.

The authors concluded that men with newly diagnosed, localized prostate cancer need to consider the trade-off between the adverse effects of surgery and radiation therapy on urinary, bowel, and sexual function with the higher risk of disease progression associated with active monitoring.

An accompanying editorial by Anthony V. D’Amico concluded that a patient should choose active surveillance only if he has a coexisting disease that is expected to decrease his life-expectancy to less than the 10 year follow-up of the ProtecT trial. If a patient does not feel comfortable with active surveillance, he should be able to achieve the same outcome with either surgery or radiation and short-course androgen-deprivation therapy.

Hamdy FC et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med. October 13, 2016; 375:1415-1424.

D’Amico A. Treatment or Monitoring for Early Prostate Cancer. N Engl J Med. October 13, 2016; 375:1482-1483

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