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Prostate Cancer: More Deadly Over Time?

Study Suggests Increasingly Aggressive Disease Decades After Diagnosis

June 8, 2004 -- The risk of dying from early-stage prostate cancer may be much greater than has been previously thought.

In the longest follow-up study to date of untreated patients with localized prostate cancer (cancer that has not spread), Swedish researchers reported a threefold rise in disease-related deaths roughly two decades after diagnosis.

The study showed that during the first 15 years after diagnosis, death related to prostate cancer averages about 15 cases for every 1,000 men. After 15 years, the death rate increases to 44 cases for every 1,000 men.

Investigators say the findings suggest a more aggressive approach is needed in treating men with the disease who have a long life expectancy.

"The clinical relevance of this finding may not be large in the United States, where aggressive treatment is already the norm," lead researcher Jan-Erik Johansson, MD, PhD, tells WebMD. "But in parts of Europe and other areas were early treatment is less common, this could have an impact."

'Watchful Waiting'

Nearly a quarter of a million men are diagnosed with prostate cancer in the U.S. each year, and the best approach to the medical management of those with localized disease remains controversial. Treatment options for men with early localized prostate cancer include surgical removal of the entire prostate, radiation therapy, or watchful waiting. Aggressive treatment, involving surgical removal of the entire prostate, is generally recommended for men with a life expectancy of a decade or more. But recent studies suggest that aggressive management has had no impact on overall prostate cancer survival rates.

Watchful waiting means a wait-and-see approach, closely monitoring a patient's condition but withholding treatment until symptoms appear or change. To see what happens during the watchful-waiting period in men with early-stage, localized prostate cancer, Johansson and colleagues followed 223 patients from central Sweden for an average of 21 years.

The researchers showed that disease progression and prostate cancer death remains fairly constant during the first 10 to 15 years. But dramatic increases in prostate cancer deaths and disease progression are seen after 15 years.

The study is published in the June 9 issue of The Journal of the American Medical Association.

Ongoing Studies

While the findings are unlikely to affect treatment strategies in the U.S., they could have major implications for several ongoing studies designed to answer key questions about the medical treatment of early-stage, localized prostate cancer, cancer prevention expert Alfred I. Neugut, MD, PhD, tells WebMD.

Two studies designed to assess the value of the controversial screening test, prostate-specific antigen (PSA), are under way, but Neugut says it appears that the follow-up times in the studies may be too short to provide meaningful information.

The introduction of PSA screening in the mid-1980s led to a dramatic rise in the diagnosis and treatment of prostate cancers. But the expected drop in prostate cancer deaths from the widespread use of this screening test has not materialized.

"Right now we have about a decade of follow-up on the impact of PSA testing," says Neugut, a professor of medicine and epidemiology at Columbia University who co-authored an editorial accompanying the study.

"Why is it so difficult to show that PSA testing works? One possibility is that it doesn't work, but another possibility is that the treatment advantage will take 20 years to show itself. We may have to completely rethink the way we study this disease."

SOURCES: Johansson, J. The Journal of the American Medical Association, June 9, 2004; vol 291: pp 2713-2719. Jan-Erik Johansson, MD, PhD, department of urology and clinical medicine, Center for Assessment of Medical Technology, Orebro University Hospital, Orebro, Sweden. Alfred I. Neugut, MD, PhD, professor of medicine, division of medical oncology, College of Physicians and Surgeons, Columbia University, New York.

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