What if I don't treat my PSA-detected prostate cancer? Answers from three natural history models

Abstract

Background: Making an informed decision about treating a prostate cancer detected after a routine prostate-specific antigen (PSA) test requires knowledge about disease natural history, such as the chances that it would have been clinically diagnosed in the absence of screening and that it would metastasize or lead to death in the absence of treatment.

Methods: We use three independently developed models of prostate cancer natural history to project risks of clinical progression events and disease-specific deaths for PSA-detected cases assuming they receive no primary treatment.

Results: The three models project that 20%-33% of men have preclinical onset; of these 38%-50% would be clinically diagnosed and 12%-25% would die of the disease in the absence of screening and primary treatment. The risk that men age less than 60 at PSA detection with Gleason score 2-7 would be clinically diagnosed in the absence of screening is 67%-93% and would die of the disease in the absence of primary treatment is 23%-34%. For Gleason score 8 to 10 these risks are 90%-96% and 63%-83%.

Conclusions: Risks of disease progression among untreated PSA-detected cases can be nontrivial, particularly for younger men and men with high Gleason scores. Model projections can be useful for informing decisions about treatment.

Impact: This is the first study to project population-based natural history summaries in the absence of screening or primary treatment and risks of clinical progression events following PSA detection in the absence of primary treatment.

Figure 1

Age-adjusted prostate cancer incidence per 100,000 men aged 50–84 observed in the core 9 registries of the Surveillance, Epidemiology, and End Results program of the National Cancer Institute and corresponding projections by the three natural history models.

Figure 2

Prostate cancer and non-prostate cancer mortality following PSA detection for cases receiving no primary treatment projected by the three models by age and grade at PSA detection. For either cause of death, lighter areas reflect agreement by all three models and darker areas reflect inter-model uncertainty. Similar risks for either cause of death and relatively greater uncertainty about survival create substantial overlap for younger men with Gleason 8–10.