Measuring Damage from "Over-Treatment" Of Indolent Prostate Cancer

June 3, 2007 -- PSA Rising -- Men who opt for surgical removal of the prostate as their primary treatment for prostate cancer face the risk of loss of sexual quality of life through loss of erectile function. A number of these men have slow-growing cancers and may be good candidates for what urologists today call "active surveillance."

A team of urologists in Brussels estimate that a third of the men currently diagnosed with prostate cancer in their service could benefit from active surveillance, avoiding loss of quality of life. Led by Paul J Van Cangh, MD, these doctors are concerned that "widespread opportunistic PSA screening of prostate cancer has resulted in a large proportion of patients aggressively treated for low burden disease," they reported at this year's annual meeting of the American Urological Association (AUA) in Anaheim California, May 19-24.

"Increased concern about overtreatment," they write, "has led to the development of active surveillance protocols. Here we have reviewed pathological characteristics, disease free survival, and quality of life of patients treated by radical prostatectomy (RP) who might have been elected for active surveillance."

Analysing records of a series of 298 PCa patients treated by RP between January, 2000 and June, 2005, Van Cangh's group defined "indolent" PCa in men with: stage T1c/T2a, one single positive sextant, Gleason score = 6, PSA <15 ng/ml, PSAd < 0,20 ng/(ml x cc). Other PCa were considered significant.

Patients were assessed 6 weeks post surgery for urinary continence. The patients sexual quality of life (QOL) was assessed using standard (EORTC QLQC30 and PR25) questionnaires.

One third of the patients -- 33% (number=97) -- were judged to have had indolent PCa with a range of 26% pT2a-b, 58% pT2c; 13% pT3a, 3% pT3b. Lymph nodes were positive in 0% of the indolent PCa. Post-surgical Gleason score was ≤ 6 in 89% and 7 in 11% of indolent PCa, while no Gleason 8 was detected. Three year PSA recurrence free survival rates were respectively 96% and 88% in the indolent group vs. 74% and 66% in the significant group.

At 3 months post RP, 43% of the patients were fully continent (no pad, no leak); 53% reported moderate incontinence (occasional pad wearing). Also by that time post-surgery "86% had interest in sex although 82% of these patients reported severe difficulties in obtaining or maintaining an erection."

Four years after surgery, 51% of the patients were fully continent while 45% reported little urine leakage. As for sex, "33% had sexual intercourse within the last months but 72% still experienced difficulties in obtaining erections."

"This retrospective analysis ," Dr. Van Cange's team concludes, "confirms that the risk of undertreating aggressive PCa is limited when electing patients for surveillance protocol based on proper selection nomograms. These could eventually spare up to one third of the patients debilitating side-effects and alteration of QOL."

SOURCE: AUA, Abstract 1157: PATHOLOGICAL CHARACTERISTICS, DISEASE FREE SURVIVAL, AND QUALITY OF LIFE OF PATIENTS TREATED BY RADICAL PROSTATECTOMY (RP) WHO MIGHT HAVE BEEN ELECTED FOR ACTIVE SURVEILLANCE. Bertrand Tombal, MD, PhD, Stéphane Thiry, MD, Yves Castilles, PhD, Axel Feyaerts, MD, Jean Pierre Cosyns, MD, PhD, Paul J Van Cangh, MD. Department of Urology, Cliniques Universitaires St. Luc, Université Catholique de Louvain, Brussels, Belgium.