Conservative management of prostate cancer in the prostate specific antigen era: The incidence and time course of subsequent therapy

Purpose: The long natural history of early stage prostate cancer is well re cognized and a conservative approach to the treatment of elderly men is oft en encouraged. We assessed the ability of patients and physicians to adhere to a policy of watchful waiting in the prostate specific antigen (PSA) era . Materials and Methods: We retrospectively reviewed the records of all 199 m en with stages T1-2 prostate cancer and PSA less than 20 ng./ml. who in our practice elected watchful waiting. Median followup in the population overa ll was 3.4 years. We performed Kaplan-Meier actuarial analysis of overall a nd disease specific survival, and most pertinent survival free from therapy . A questionnaire was administered to record the attitude of patients who u ltimately proceeded to treatment to determine how therapy was triggered. Results: Median patient age was 71 years and median PSA was 6.6 ng./ml. The tumor was impalpable in 52% of patients, Gleason sum was 6 or less in 80% and 11% used some form of herbal remedy or nutritional supplementation. Of the 37 men who died during observation, including 35 of co-morbid illness, only 6 underwent treatment. Overall survival at 5 and 7 years was 77% and 6 3% but disease specific survival was 98% and 98%, respectively. A total of 64 patients underwent treatment and actuarial freedom from treatment was 56 % at 5 years, including 51% and 73% in those younger and older than 75 year s at diagnosis. The likelihood of being alive and free from treatment was 4 3% at 5 years and 26% at 7. Of the 63 men treated 48 (76%) underwent radica l therapy (brachytherapy in 17, external beam radiotherapy in 29 and prosta tectomy in 2), while only 24% received androgen deprivation. The median PSA increase from diagnosis to treatment in treated patients was 2.9 ng./ml., and it was 0.9 ng./ml. from diagnosis to the last followup in those not tre ated. Of the treated patients 81% believed that the physician had initiated therapy due to a PSA increase or a nodule. However, physicians recorded ha ving advocated treatment in only 24% of cases. Conclusions: When patients do not die of co-morbid illness, they are likely to proceed to therapy well within the first decade after diagnosis (57% by 5 years and 74% by 7). Therapy was usually definitive (radical) and trigge red by slight, inevitable PSA increases. The patient perception was that th e physicians initiated therapy in response to increasing PSA. However, the physicians more often perceived that treatment was initiated by patients. T herefore, watchful waiting in the PSA era often represents radical therapy delayed by a few years.