Non-metastatic prostate cancer: is having no treatment acceptable?

This study aimed to compare the standard of care and survival in patients diagnosed with non-metastatic prostate cancer. 

Non-metastatic prostate cancer is cancer that has not yet spread beyond the prostate.  There are several ways to treat this disease including radical prostatectomy (RP: surgical removal of the prostate) or high-dose radiotherapy with or without hormone therapy to reduce testosterone levels (RAD). These are defined as local treatments, as they target the tumor directly. Prostate cancer is now being caught earlier and earlier, treatment is often started before it is clear whether the tumor is aggressive or not. This can result in either undertreatment or overtreatment, with both being associated with increased risk of death. 

The study was conducted on 3,486 patients who were < 75 years old and had a diagnosis of non-metastatic disease. Patients were placed into three groups; those who had undergone RP (895), RAD (1,339) or no local treatment (1,252). Low-risk tumors were defined as a prostate-specific antigen (PSA) level <10 µg/L, Gleason score (a method of classifying cancer based on the appearance of the cells under the microscope) of <6 and stage T1-T2a (classifying the cancer based on the size of the tumor). High-risk tumors had a PSA level of >20 µg/L, Gleason score 8-10 and stage T2c or above.

In those with low-risk tumors, regardless of treatment, fewer than 1% of deaths were due to cancer. In the high-risk patients, the rate of survival was significantly higher in the groups that RP (97.7%) and RAD (97.2%) compared to the group that received no local treatment at all (85.9%). Compared to those with a low-risk tumor, those with a high-risk tumor had a significantly increased risk of death from prostate cancer.  

The authors concluded that patients with low-risk tumors should be informed about the option of observing their tumor (active surveillance). Conversely, local treatment should be offered to high-risk patients. 

There was no information about co-existing diseases, which may have affected treatment selection. 

Dependent on your risk status, discuss the possibility of observation compared to local treatment for your prostate cancer.