Prostate Cancer Natural History

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The natural history of prostate cancer progression is often confounded by other competing causes of mortality. This has been further affected by tumor stage designations defined by PSA status since it introduces a lead time bias, and because only limited long term data are available.

• In general, those patients with low grade disease have a 10% or less mortality rate over 10 years; while those with high grade disease have a 60% probability of a prostate cancer related death. Patients with moderate grade disease have a 13% disease specific mortality but a 40% chance of tumor progression over a decade.
• The largest study with longest follow-up was reported in Sweden by Johansson and colleagues in 2004 where 223 patients underwent surveillance for localized disease for a mean of 21 years. Forty percent of patients developed progression and 17% developed generalized disease on follow-up, with a prostate cancer related mortality of 16% for all patients and 22% for patients younger than 70 years at diagnosis. Prostate cancer related mortality was significantly higher after 15 years of follow-up (44 per 1000 person-years) compared with 15 per 1000 person-years during the first 15 years. These data suggest that even in a cohort of men with competing co-morbidities and well or moderately differentiated tumors (96%), local tumor progression and aggressive metastatic disease may develop in the long term.
• Holmberg and colleagues of the Scandinavian Prostatic Cancer Group randomized 695 men with localized prostate cancer to watchful waiting or radical prostatectomy. Despite a short median follow-up of 6.2 years, prostate cancer specific mortality was almost double (8.9%) in the observation arm compared with the radical prostatectomy group (4.6%). There was no difference in overall survival, likely a reflection of the short follow-up of the study.
• Patients who experience a biochemical failure of disease after local treatment have a median survival of 13 years ranging from 7-20 years depending on multiple clinical factors.
• Data from the Connecticut tumor registry demonstrate the impact of Gleason pattern [grade] 4 disease on surgical mortality
• Classic metastatic bone disease has a median survival of 27-33 months, 75 percent mortality at 5 years, and 90% at 10 years.
• Clinical androgen resistant prostate cancer has a median survival of 11 months.

References

• Johansson JE, Andren O, Andersson SO, Dickman PW, Holmberg L, Magnuson A, Adami HO. Natural history of early, localized prostate cancer.JAMA. 2004 Jun 9;291(22):2713-9.
• Holmberg L, Bill-Axelson A, Helgesen F, Salo JO, Folmerz P, Haggman M, Andersson SO, Spangberg A, Busch C, Nordling S, Palmgren J, Adami HO, Johansson JE, Norlen BJ: A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med. 2002 Sep 12;347(11):781-9.