Deferring Treatment in Men With Low and Low-Intermediate Risk Prostate Cancer Does Not Adversely Affect Outcome

Abstract

Deferring treatment in men who present with low and low intermediate risk prostate cancer is actively championed as a appropriate care for this group of patients. However it is often difficult for a patient to reconcile the idea of doing nothing when told they have cancer and advertisements for safe noninvasive treatment assail them on every front. This study attempts to provide data on long term follow up of a group who did not immediately choose treatment. Between 2000 and 2015, 2437 men were diagnosed with prostate cancer in a VA Healthcare facility. Eleven percent or 274 patients elected a course of watchful waiting or active surveillance. Thirty three percent or 89 of these men deferred treatment for more than 12 months and then elected to pursue treatment. We reviewed the reasons for selecting treatment and as well as the results of treatment. The majority of patients (95.5%). were Gleason’s 6 (70%) or 7 (25%) The median duration for deferring treatment in the Gleason 6 cohort was 31 months and for the Gleason 7 group it was 19 months. Eighty men (94%) eventually received curative therapy; surgery or radiation +/-hormonal therapy or hormonal therapy alone.Five men consistently refused treatment and ultimately started hormonal therapy when diagnosed with bone mets and survived between 9.5 and 14 years. The reasons why patients chose to start treatment in the Gleason 6 group were: increasing Gleason’s score on rebiopsy (22), increasing PSA (16), physician’s advice (16) personal choice (6) metastatic disease (4) and other(4). Three of the 4 men starting for mets had PSA values >100ng/ml. In the Gleason 7 group the reasons were similar: Increased PSA (9), increasing Gleasons score on rebiopsy (5), physician’s advice (4) personal choice (3) metastatic disease (1). The patients treated for curative intent have a median follow up of 50 months (3-84 months) in the Gleason 6 group and 60 months (7-166 months) in the Gleason 7 group. The survival since diagnosis ranges from 26 to 273 months for the Gleason 6 patients ( median 67 months) and 29 to 180 months for the Gleason 7 patients, (median 78 months). Of the 80 patients, 54 are bNED, 17 are cNED, 6 are AWD, 2 DWD and I DOD. Among men who elected only hormonal therapy the median follow since diagnosis up is 154 months for Gleason 6 and 94 months for Gleason 7. Also only 4 patients actually died of disease and 3 of these were in the group who chose no treatment until they developed bone mets. With only 4 relapses and 1 death among the 85 Gleason 6 and 7 tumors, a 100% survival would fall within the 95% confidence interval. Men with Gleason score 6 tumors and low-intermediate risk Gleason 7 tumors may defer treatment with active surveillance and follow-up biopsies without compromising their prostate cancer specific survival. This has important implications for assessing the risks vs. benefits of prostate cancer screening programs.