Dr. Laurence H. Klotz, Sunnybrook Medical Science Center presented the argument for active surveillance with delayed intervention. There are 2.74 million men age 50-70 in the US with a PSA >2.5ng/ml. He cited the 20-40 year natural history of CaP and approximately 10-year lead-time bias. Most men who die from CaP die from intermediate-high risk CaP. For favorable risk patients with low risk CaP, WW with delayed intervention is a sound approach according to Dr. Klotz's data. Without treatment, there is 99% CaP specific survival at 9.5 years, even with 45% of patients ultimately getting treated. High-risk patients will be detected by following the PSA doubling time and thus intervention can be implemented. PSA doubling time in <3 years when followed at 3 month intervals for 2 years, then at 6 month interval will identify the 20% of patients that need intervention. In addition, a prostate biopsy at year 1 then every 3-4 years will assess for increasing grade migration. At 10 years, Dr. Klotz showed a >95% year survival in the Toronto surveillance experience. But what is the risk of this approach asked Dr. Klotz? Based on the Swedish RP vs. WW trial data, RP offers a 44% risk reduction in mortality at 10 years. For each CaP death avoided 19 RPs had to be performed according to Dr. Klotz's analysis. Yet these patients were not a screened population and included a cohort of much higher risk patients. As such, the outcomes for observation would be much better. The 16% mortality data at 10 years when adjusted for lead time bias, grade shift and opportunity for salvage (estimated at 50%) would translate into treating 54-90 patients with RP to avoid one death. Of the patients eventually needing RP for a rapid doubling time, 48% were pT3, but very few of these actually died of CaP.

Dr. Peter T. Scardino, Memorial Sloan Kettering Cancer Center presented the case for treatment. Dr. Scardino focused on the excellent outcomes of treatment, with an emphasis on radical prostatectomy. He cited the survival rates for patients undergoing treatment and the high likelihood of preservation of continence and sexual function. He also cited the Swedish RP vs. WW trial data, but emphasized that the difference in mortality rates at 10 years was already apparent by 5 years. Dr. Scardino stated that the average age of his patient undergoing RP is 57 years, with a 25-year life expectancy, not just 10 years. The Johanssen study supported this concept, where the CaP mortality at 21 years was significantly greater than at 15 years. He also pointed out that biopsies underestimate the grade of the tumor by 17-35%. One third of patients who actually die of CaP had an initial Gleason score 6 CaP. He argued that treatment in low risk patients has excellent oncologic outcomes and 80% will be cancer free, continent and potent at 2 years post-op. Dr. Scardino stated that based upon these data, active treatment for CaP is attractive and avoids additional toxicity of salvage therapy.

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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