ABSTRACT:
Temporarily Deferred Therapy (Watchful Waiting) for Men Younger Than 70 Years
and With Low-Risk Localized Prostate Cancer in the Prostate-Specific Antigen Era
Carter
CA, Donahue T, Sun L, et al
Journal of Clinical Oncology. 2003;21(21):4001-4008
A
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This retrospective cohort study identified 318 men diagnosed with early prostate
cancer between 1991 and 2002, who initially chose WW rather than definitive local
therapy. All patients had low clinical stage (
The median age was 65.4 years, and median follow-up was 3.8 years. Only 98 patients
remained on WW after this time, and the remaining 215 proceeded with local therapy.
Likelihood of continuing WW was strongly predicted by initial clinical stage (T1a/1b
vs others) and by PSA doubling time (DT). The median PSA DT was 25.8 years for
those who remained on WW and 2.5 years for those who abandoned WW. Predictably,
the type of local therapy ultimately chosen depended upon a number of comorbidities.
Patients with fewer than 2 comorbidities more frequently chose RP or BT, while
patients with 2 or more comorbidities most often opted for ERT.
Although WW is an accepted approach in patients with early, good-risk prostate
cancer whose life expectancy is 10 years or less, this approach is not well validated
in younger patients. This study retrospectively identified more than 300 men in
the United States under age 70 years who chose this approach, and found that the
majority quickly switched over to definitive local therapy, including 57% by 2
years and 73% by 4 years. There is no well-defined algorithm for surveillance
in patients being managed with WW, and most practitioners will follow clinical
examination, PSA, PSA DT, and repeat biopsy at regular intervals to aid in decision-making.
The optimal frequency, and value, of repeat biopsy is unknown and was not discussed
in this study, since only 77 patients received repeat biopsies. PSA and PSA DT
are often used as the primary decision-making tools, and indeed in this study
shorter PSA DT constituted the most important criterion for treatment.
The clinical outcome of patients in this study is unknown due to the short follow-up.
The outcome from patients who initially chose WW and then crossed over to definitive
local therapy will be compared in a future study with similar patients who initially
chose definitive local therapy. It is unlikely that a statistically significant
difference in outcome would be observed in a cohort of this size with good-risk
features, even with long-term follow-up. Rather than validating the approach of
WW in younger patients, this study highlights the reality of prostate cancer therapy
for most patients in the United States; WW is more properly termed "temporarily
deferred therapy," as the title of the article suggests. Studies outside the United
States, such as the Scandinavian Prostatic Cancer Group Study Number 4,[1]
are more likely to speak to the clinical validity of watchful waiting.
Reference
1. Holmberg L, Bill-Axelson A, Helgesen F, et al.
A randomized trial comparing radical prostatectomy with watchful waiting in early
prostate cancer. N Engl J Med. 2002;347:781-789.