The changing face of low-risk prostate cancer: trends in clinical presentation and primary management

Abstract

Purpose: Early intervention for prostate cancer is associated with excellent long-term survival, but many affected men, especially those with low-risk disease characteristics, might not experience adverse impact to survival or quality of life were treatment deferred. We sought to characterize temporal trends in clinical presentation and primary disease management among patients with low-risk prostate cancer.

Methods: Data were abstracted from the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a disease registry of 8,685 men with various stages of prostate cancer. Included were 2,078 men who were diagnosed between 1989 and 2001 and had a serum prostate specific antigen </= 10 ng/mL, Gleason sum </= 6, and clinical T stage </= 2a. Trends in risk distribution, tumor characteristics, and primary treatment were evaluated.

Results: The proportion of patients with low-risk tumor characteristics rose from 29.8% in 1989 to 1992, to 45.3% in 1999 to 2001 (P <.0001). There have been sharp increases in the use of brachytherapy and androgen deprivation monotherapy, from 3.1% and 3.1%, to 12.0% and 21.7%, respectively. Utilization rates for prostatectomy, external-beam radiotherapy, and observation have fallen accordingly, from 63.8%, 16.1%, and 13.8%, to 51.6%, 6.8%, and 7.9% (P <.0001 for all except prostatectomy [P =.0019]). Age and socioeconomic status were significantly associated with treatment selection, but overall, the treatment trends were echoed on subgroup analysis of patients 75 years or older.

Conclusion: Low-risk features characterize a growing proportion of prostate cancer patients, and there have been significant shifts in the management of low-risk disease. Overtreatment may be a growing problem, especially among older patients.

Figure 1

Time trends in clinical characteristics among low-risk patients For each time period, percentages of tumors in each clinical T stage (panel A), Gleason score (panel B), and PSA range (panel C) are presented.

Figure 2

Treatment trends among low-risk prostate cancer patients Trends for each primary treatment alternative are significant at the p<.0001 level, with the exception of RP, which is significant with p=.0019.

Figure 3

Treatment trends among low-risk prostate cancer patients 75 years of age or older p-values for significant trends are as follows: EBRT p=.0005, brachy p<.0001, PADT p=.0492, WW p=.0048. The trend for RP is not significant, p=.96.