Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience

Abstract

Purpose: We updated our experience with a strategy of expectant treatment for men with stage T1c prostate cancer and evaluated predictors of disease intervention.

Materials and methods: A total of 407 men with a median age of 65.7 years (range 45.8 to 81.5) with stage T1c (99.8%) or T2a (0.2%) prostate cancer suspected of harboring small volume prostate cancer based on needle biopsy findings and prostate specific antigen density have been followed in a prospective, longitudinal surveillance program with a median followup of 2.8 years (range 0.4 to 12.5). A recommendation for treatment was made if disease progression was suggested by unfavorable followup needle biopsy findings (Gleason pattern 4 or 5, greater than 2 biopsy cores with cancer or greater than 50% involvement of any core with cancer). Cox proportional hazards regression was used to evaluate the affect of multiple covariates on the outcome of curative intervention.

Results: Of 407 men 239 (59%) men remained on active surveillance at a median followup of 3.4 years (range 0.43 to 12.5), 103 (25%) underwent curative intervention at a median of 2.2 years after diagnosis (range 0.96 to 7.39) and 65 (16%) were either lost to followup (12), withdrew from the program (45), or died of causes other than prostate cancer (8). Older age at diagnosis (p = 0.011) and an earlier date of diagnosis (p = 0.001) were significantly associated with curative intervention.

Conclusions: Recognizing that over treatment of prostate cancer is prevalent, especially among elderly patients, a program of careful selection and monitoring of older men who are likely to harbor small volume, low grade disease may be a rational alternative to the active treatment of all.

Fig. 1

Kaplan-Meier estimate of treatment-free survival in 407 men in expectant management program.

Fig. 2

PSAD, PSAV, percent free PSA, PSA, age at diagnosis and PSADT in men who met all expectant management entry criteria, as described. Boxes represent IQR. Horizontal lines in boxes represent median. Vertical lines represent 1.5 times IQR with outlying PSADT values that exceeded 1.5 times IQR removed for illustration purposes.